28 Tex. Admin. Code § 11.2203 - Minimum Standards - Dental Care Services and Benefits

(a) Each single service HMO evidence of coverage that uses any dental procedure codes must use the codes as specified in the current version of the CDT and certify that the codes referenced in its evidence of coverage are as specified in the current version of the CDT.

(b) Each single service HMO evidence of coverage providing coverage for dental care services must provide benefits for covered dental treatment in progress and may, if clearly disclosed, require the enrollee to have the treatment completed by a participating provider in the HMO delivery network, as defined in Insurance Code § 843.002 (concerning Definitions), or as otherwise arranged by the single service HMO.

(c) Each single service HMO evidence of coverage providing coverage for dental care services and benefits must provide services for the purposes of preventing, alleviating, curing, or healing dental disease, including dental caries and periodontal disease. The services may include an infection control (sterilization) fee. Single service HMOs providing coverage for dental care services must provide coverage for the following primary and preventive services provided by a general dentist or hygienist, as applicable:

(1) office visit during and after regularly scheduled hours;

(2) oral evaluations;

(3) X-rays;

(4) bitewings;

(5) panoramic film;

(6) dental prophylaxis (adult and child);

(7) topical fluoride treatment for children;

(8) dental sealants for children;

(9) amalgam fillings (one, two, three, and four or more surfaces, primary and permanent, including polishing);

(10) anterior resin fillings (one, two, three, and four or more surfaces, or involving incisal angle, primary and permanent, including polishing);

(11) simple oral extractions;

(12) surgical incision and drainage of abscess, intraoral soft tissue; and

(13) palliative (emergency) treatment of dental pain, provided that the enrollee may obtain emergency treatment of dental pain in a comparable facility.

(d) Each single service HMO evidence of coverage providing coverage for dental care services and benefits may provide secondary dental care services and benefits. Each single service HMO evidence of coverage providing coverage for dental care services and benefits may include an infection control (sterilization) fee, and may provide secondary dental care services and benefits, including:

(1) posterior resin restorations, one, two, three, and four or more surfaces (to include polishing);

(2) crowns and crown recementation;

(3) composite resin crowns, anterior-primary;

(4) sedative fillings;

(5) core buildup, including any pins, and pin retention;

(6) pulp cap (direct and indirect);

(7) therapeutic pulpotomy;

(8) root canal therapy, anterior, bicuspid, and molar;

(9) gingival curettage;

(10) osseous surgery;

(11) periodontal scaling and root planing;

(12) periodontal maintenance procedures;

(13) complete denture (maxillary and mandibular);

(14) partial denture (maxillary and mandibular);

(15) root removal-exposed roots;

(16) surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone or section of tooth;

(17) removal of impacted tooth (soft tissue and completely bony);

(18) tooth reimplantation or stabilization, or both, of accidentally evulsed or displaced tooth or alveolus, or both;

(19) alveoplasty;

(20) occlusal guard (bruxism appliance); or

(21) orthodontia.

(e) Each single service HMO providing coverage for dental care services and benefits may also offer a preventive services plan as a supplement to a basic health care service plan offered by an affiliate or another carrier, as long as a plan described in subsection (c) of this section has first been offered to and rejected in writing by the group contract holder. The preventive plan must include:

(1) oral evaluations;

(2) X-rays;

(3) bitewings;

(4) panoramic film; and

(5) prophylaxis.

Notes

28 Tex. Admin. Code § 11.2203

The provisions of this §11.2203 adopted to be effective November 2, 1998, 23 TexReg 11347; amended to be effective February 24, 2005, 30 TexReg 854; Adopted by Texas Register, Volume 42, Number 16, April 21, 2017, TexReg 2212, eff. 8/1/2017