Cal. Code Regs. Tit. 10, § 2699.6713 - Excluded Dental Benefits for All Subscribers

(a) A dental benefits plan offered under this program shall exclude:

(1) Any benefits specified as excluded within Section 2699.6709 or Section 2699.6711.

(2) Any benefits in excess of limits specified in Section 2699.6709 or Section 2699.6711.

(3) Services, supplies, items, procedures or equipment, which are not medically necessary as determined by the plan, unless otherwise specified in Section 2699.6709 or Section 2699.6711.

(4) Any benefits received or costs that were incurred in connection with any dental procedures started prior to the subscriber's effective date of coverage. This exclusion does not apply to covered services to treat complications arising from services received prior to the subscriber's effective date of coverage.

(5) Any benefits that are received subsequent to the time the subscriber's coverage ends.

(6) Experimental or investigational services, including any treatment, therapy, procedure, drug or drug usage, facility or facility usage, equipment or equipment usage, device or device usage, or supply which is not recognized as being in accordance with generally accepted professional medical standards, or for which the safety and efficiency have not been determined for use in the treatment of a particular illness, injury or medical condition for which the item or service in question is recommended or prescribed.

(7) Dental services that are received in an emergency care setting for conditions that are not emergencies if the subscriber reasonably should have known that an emergency care situation did not exist.

(8) Procedures, appliances, or restorations to correct congenital or developmental malformations are not covered benefits unless specifically listed in Section 2699.6709 or Section 2699.6711.

(9) Cosmetic dental care.

(10) General anesthesia or intravenous/conscious sedation unless specifically listed as a benefit or is given by a dentist for covered oral surgery.

(11) Hospital charges of any kind.

(12) Major surgery for fractures and dislocations.

(13) Loss or theft of dentures or bridgework.

(14) Malignancies.

(15) Dispensing of drugs not normally supplied in a dental office.

(16) Additional treatment costs incurred because a dental procedure is unable to be performed in the dentist's office due to the general health and physical limitations of the subscriber.

(17) The cost of precious metals used in any form of dental benefits.

(18) The surgical removal of implants.

(19) Services of a pedodontist/pediatric dentist for subscriber children except when a subscriber child is unable to be treated by his or her panel provider, or treatment by a pedodontist/pediatric dentist is medically necessary, or his or her panel provider is a pedodontist/pediatric dentist.

Notes

Cal. Code Regs. Tit. 10, § 2699.6713

1. New section filed 2-20-98 as an emergency; operative 2-20-98 (Register 98, No. 8). A Certificate of Compliance must be transmitted to OAL by 6-22-98 or emergency language will be repealed by operation of law on the following day.
2. Certificate of Compliance as to 2-20-98 order transmitted to OAL 6-5-98 and filed 7-15-98 (Register 98, No. 29).
3. New subsection (d) filed 3-21-2000 as an emergency; operative 3-21-2000 (Register 2000, No. 12). A Certificate of Compliance must be transmitted to OAL by 7-19-2000 or emergency language will be repealed by operation of law on the following day.
4. Certificate of Compliance as to 3-21-2000 order transmitted to OAL 6-23-2000 and filed 7-17-2000 (Register 2000, No. 29).
5. Renumbering of former section 2699.6713 to section 2699.6715 and renumbering of former section 2699.6711 to section 2699.6713, including amendment of section heading, section and NOTE, filed 4-29-2002 as an emergency; operative 4-29-2002 (Register 2002, No. 18). Pursuant to Chapter 946, Statutes of 2000, section 2, a Certificate of Compliance must be transmitted to OAL by 10-28-2002 or emergency language will be repealed by operation of law on the following day.
6. Certificate of Compliance as to 4-29-2002 order, including repealer of subsection (a)(8) and subsection renumbering, transmitted to OAL 10-28-2002 and filed 12-12-2002 (Register 2002, No. 50).
7. Amendment filed 9-15-2008; operative 10-15-2008 (Register 2008, No. 38).

Note: Authority cited: Sections 12693.21 and 12693.755, Insurance Code. Reference: Sections 12693.21, 12693.63 and 12693.755, Insurance Code.

1. New section filed 2-20-98 as an emergency; operative 2-20-98 (Register 98, No. 8). A Certificate of Compliance must be transmitted to OAL by 6-22-98 or emergency language will be repealed by operation of law on the following day.
2. Certificate of Compliance as to 2-20-98 order transmitted to OAL 6-5-98 and filed 7-15-98 (Register 98, No. 29).
3. New subsection (d) filed 3-21-2000 as an emergency; operative 3-21-2000 (Register 2000, No. 12). A Certificate of Compliance must be transmitted to OAL by 7-19-2000 or emergency language will be repealed by operation of law on the following day.
4. Certificate of Compliance as to 3-21-2000 order transmitted to OAL 6-23-2000 and filed 7-17-2000 (Register 2000, No. 29).
5. Renumbering of former section 2699.6713 to section 2699.6715 and renumbering of former section 2699.6711 to section 2699.6713, including amendment of section heading, section and Note, filed 4-29-2002 as an emergency; operative 4-29-2002 (Register 2002, No. 18). Pursuant to Chapter 946, Statutes of 2000, section 2, a Certificate of Compliance must be transmitted to OAL by 10-28-2002 or emergency language will be repealed by operation of law on the following day.
6. Certificate of Compliance as to 4-29-2002 order, including repealer of subsection (a)(8) and subsection renumbering, transmitted to OAL 10-28-2002 andfiled 12-12-2002 (Register 2002, No. 50).
7. Amendment filed 9-15-2008; operative 10-15-2008 (Register 2008, No. 38).