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Health Fund

Looking At Eligible And Ineligible Expenses

Eligible Expenses

The Dental Plan covers a wide range of services, including those described below. If you want to know whether a particular service is covered, contact the Delta Dental office. (See the Summary of Benefits, page 16 for contact information.)

Once you satisfy the deductibleThe amount you must pay for covered services in a plan year before the plan begins to pay benefits., the plan will pay the appropriate coinsurance The percentage of eligible expenses you're responsible for paying. (based on the negotiated rate for in-network services or based on R&C charges for non-network services) for necessary treatment under the Generally Accepted Standards of dental practice.

Basic Benefits

Basic benefits include:

  • Adjunctive general services (e.g., general anesthesia; office visit for observation; office visit after regularly scheduled hours; therapeutic drug injection; treatment of post-surgical complications/unusual circumstances; and limited occlusal adjustment);
  • Endodontics (treatment of the tooth pulp);
  • Oral surgery (extractions and certain other surgical procedures, including pre- and post-operative care); and
  • Restorative services (amalgam, silicate or composite/resin restorations/fillings for treatment of carious lesions/visible destruction of hard tooth structure resulting from the process of dental decay).
Crowns, Jackets, Inlays, Onlays and Cast Restoration Benefits

Benefits for the above services are provided only if the dental care is provided to treat cavities that cannot be restored with amalgam, silicate or direct composite/resin restorations.

Diagnostic and Preventive Benefits

Diagnostic and preventive benefits include:

  • Diagnostic work (e.g., oral examinations, including initial examinations, periodic examinations and emergency examinations; X-rays; diagnostic casts; examination of biopsied tissue; palliative/emergency treatment of dental pain; and specialist consultation);
  • Preventive care (e.g., prophylaxis/cleaning; fluoride treatment; and space maintainers); and
  • Sealants for covered children up to age 14 (topically applied acrylic, plastic or composite material used to seal developmental grooves and pits in teeth for the purpose of preventing dental decay).
Implant Benefits

These include prosthetic appliances placed into or on bone of the maxillar or mandible (upper or lower jaw) to retain or support dental prostheses, including endosseous, transosseous, subperiosteal, and endodontic implants; implant connecting bars; implant repairs; and implant removal.

Orthodontic Benefits

These include procedures using appliances or surgery to straighten or realign teeth that otherwise would not function properly. Subject to any regulatory guidance to the contrary, these benefits are deemed to be non-essential health benefits and are available only for covered children up to age 19.

Prosthodontic Benefits

These include construction or repair of fixed bridges, partial dentures and complete dentures (which is covered if provided to repair missing natural teeth) occlusal orthotic devices, removable metal overlay stabilizing appliances, and occlusal guards.

Plan Limitations

The following limitations apply to your dental coverage:

  1. Bitewing X-rays are provided on request by the dentistA doctor of dentistry who is licensed to practice dentistry at the time and place involved where the particular dental procedure was rendered., but no more than once in a six-month period.
  2. Implants are covered once every five years.
  3. Crowns, jackets, inlays, onlays and cast restorations are covered on the same tooth once every five years, unless Delta Dental determines that replacement is required because the restoration is unsatisfactory as the result of poor quality of care, or because the tooth involved has experienced extensive loss or changes to tooth structure or supporting tissues since the replacement of the restoration.
  4. The Dental Plan will pay the applicable percentage of the dentist's fee for a standard partial or complete denture, up to a maximum fee allowance. This fee allowance is the fee that would satisfy the majority of Delta Dental dentists. A standard partial or complete denture is one made from accepted materials and by conventional methods. The Maximum Fee Allowance is revised periodically, as dental fees change. If your dentist's accepted fee on file with Delta Dental for a partial or complete denture is higher than this maximum allowance, you will be required to pay that portion of his/her fee that exceeds Delta Dental's allowance in addition to your portion of the allowance
  5. The Dental Plan's payments for orthodontic treatment will stop when the first payment is due to the dentist following either a loss of eligibility or the termination of treatment for any reason before it is completed.
  6. Full mouth X-rays and panoramic X-rays are covered only once in a three-year period.
  7. If orthodontic treatment is begun before you become eligible for coverage, the Plan's payments will begin with the first payment due to the dentist following your eligibility date.
  8. If you select a more expensive treatment plan than is customarily provided, or specialized techniques, an allowance will be made for the least expensive professionally acceptable alternative treatment plan. The Dental Plan will pay the applicable percentage of the lesser fee for the customary or standard treatment, and you will be responsible for the remainder of the dentist's fee.
  9. Only the first two oral examinations in a 12-month period are covered.
  10. Orthodontic payment is limited to treatment of covered children up to age 19.
  11. Prosthodontic appliances are covered once every five years, unless Delta Dental determines that there has been such an extensive loss of remaining teeth or change in supporting tissues that the existing appliance cannot be made satisfactory. Replacement of a prosthodontic appliance not provided under a Delta Dental plan will be made if it is unsatisfactory and cannot be made satisfactorily.
  12. Replacement implants are covered only following a five-year period after installation of an original implant provided under any Delta Dental plan.
  13. Sealant benefits are limited to covered children up to age 14. Sealant benefits include the application of sealants only to permanent posterior molars without caries (decay), without restorations and with the occlusal surface intact. Sealant benefits do not include the repair or replacement of a sealant on a tooth within three years of its application.
  14. Three cleanings or procedures that include a cleaning or combination thereof are covered every calendar year (January through December).
  15. X-rays and extractions that might be necessary for orthodontic treatment are not covered by orthodontic benefits, but may be covered under diagnostic and preventive or basic benefits.
  16. Full-mouth debridement (gross scale) is limited to one treatment in a lifetime
  17. Periodontal treatments (root planing/subgingival curettage) are limited to four quadrants during any 24 consecutive months.

Ineligible Expenses

The Dental Plan covers a wide range of dental services, but there are some services that are not covered. It is important for you to know what these services are before you visit your dentist.

The Dental Plan doesn't cover the following services:

  1. Anesthesia and intravenous (IV) sedation, except for general anesthesia given by a dentist for covered oral surgery procedures and/or for select endodontic and periodontal procedures;*
  2. Charges by any hospital or other surgical or treatment facility and any additional fees charged by the dentist for treatment in any such facility;
  3. Charges for replacement or repair of an orthodontic appliance paid in part or in full by the Plan;
  4. Diagnosis or treatment by any method of any condition related to the temporomandibular (jaw) joints or associated muscles, nerves or tissues;
  5. Experimental procedures;
  6. Grafting of tissues from outside the mouth to tissues inside the mouth ("extraoral grafts");
  7. Complete occlusal adjustment;
  8. Prescribed drugs or applied therapeutic drugs, premedication or analgesia;
  9. Replacement of existing restoration for any purpose other than restoring active tooth decay or fracture of the restoration;
  10. Services for cosmetic purposes or for conditions that are the result of hereditary or developmental defects, such as cleft palate, upper and lower jaw malformations, congenitally missing teeth and teeth that are discolored or lacking enamel;
  11. Services for injuries covered by Workers' Compensation or employer's liability laws;
  12. Services for restoring tooth structure lost from wear (e.g., abrasion, erosion, attrition or abfraction), for rebuilding or maintaining chewing surfaces due to teeth out of alignment or occlusion, or for stabilizing the teeth. (Examples of such treatment are equilibration and periodontal splinting); and
  13. Services that are provided by any Federal or State government agency or that are provided without cost by any municipality, county or other political subdivision, except Medi-Cal benefits.

*Anesthesia is covered for the following endodontic and periodontal procedures:

Endodontic Procedures
Code Procedure
D3410 Apicoectomy/periadicular surgery – anterior
D3421 Apicoectomy/periadicular surgery – bicuspid (first root)
D3425 Apicoectomy/periadicular surgery – molar (first root)
D3426 Apicoectomy/periadicular surgery (each additional root)
D3450 Root amputation – per root
D3920 Hemisection (including any root removal, not including canal therapy

Periodontic Procedures
Code Procedure
D4240 Gingival flap procedure, including root planing – four or more contiguous teeth or tooth bounded spaces per quadrant
D4241 Gingival flap procedure, including root planning – one to three contiguous teeth or tooth bounded spaces per quadrant
D4260 Osseous surgery (including flap entry and closure) – four or more contiguous teeth or tooth bounded spaces per quadrant
D4261 Osseous surgery (including flap entry and closure) – one to three contiguous teeth or tooth bounded spaces per quadrant
D4263 Bone replacement graft – first site in quadrant
D4264 Bone replacement graft – each additional site in quadrant
D4266 Guided tissue regeneration – resorbable barrier, per site
D4267 Guided tissue regeneration – non-resorbable barrier, per site (includes membrane removal)
D4273 Subepithelial connective tissue graft procedures, per tooth
D4276 Combined connective tissue and double pedicle graft, per tooth