A health benefit plan must include "pediatric dental
benefits" in its essential health benefits package. Pediatric dental benefits
means coverage for the oral services listed in subsection (3) of this section,
delivered to those under age nineteen.
(1) For benefit years beginning January 1,
2015, a health benefit plan must include pediatric dental benefits as an
embedded set of benefits, or through a combination of a health benefit plan and
a stand-alone dental plan that includes pediatric dental benefits certified as
a qualified dental plan. For a health benefit plan certified by the health
benefit exchange as a qualified health plan, this requirement is met if a
stand-alone dental plan meeting the requirements of subsection (3) of this
section is offered in the health benefit exchange for that benefit
year.
(2) The requirements of WAC
284-43-5640 and
284-43-5780 are not applicable to
the stand-alone dental plan. A health benefit plan may, but is not required to,
include the following services as part of the EHB-benchmark package. The
supplemental base-benchmark plan specifically excludes oral implants, and an
issuer should not include benefits for oral implants in establishing a plan's
actuarial value.
(3)
Supplementation: The base-benchmark plan covers pediatric services
for the categories set forth in WAC
284-43-5640, but does not cover
pediatric oral services. Because the base-benchmark plan does not cover
pedi-atric oral benefits, the state EHB-benchmark plan requirements are
supplemented for pediatric oral benefits. The Washington state CHIP plan is
designated as the supplemental base-benchmark plan for pediatric dental
benefits. A health plan issuer must offer coverage for and classify the
following pediatric oral services as pediatric dental benefits in a manner
substantially equal to the supplemental base-benchmark plan:
(a) Diagnostic services;
(b) Preventive care;
(c) Restorative care;
(d) Oral surgery and reconstruction to the
extent not covered under the hospitalization benefit;
(e) Endodontic treatment;
(f) Periodontics;
(g) Crown and fixed bridge
(h) Removable prosthetics; and
(i) Medically necessary
orthodontia.
(4) The
supplemental base-benchmark plan's visit limitations on services in this
category are:
(a) Diagnostic exams once every
six months, beginning before one year of age;
(b) Bitewing X ray once a year;
(c) Panoramic X rays once every three
years;
(d) Prophylaxis every six
months beginning at age six months;
(e) Fluoride three times in a twelve-month
period for ages six and under; two times in a twelve-month period for ages
seven and older; three times in a twelve-month period during orthodontic
treatment; sealant once every three years for occlusal surfaces only; oral
hygiene instruction two times in twelve months for ages eight and under if not
billed on the same day as a prophylaxis treatment;
(f) Every two years for the same restoration
(fillings);
(g) Frenulectomy or
frenuloplasty covered for ages six and under without prior
authorization;
(h) Root canals on
baby primary posterior teeth only;
(i) Root canals on permanent anterior,
bicuspid and molar teeth, excluding teeth 1, 16, 17 and 32;
(j) Periodontal scaling and root planing once
per quadrant in a two-year period for ages thirteen and older, with prior
authorization;
(k) Periodontal
maintenance once per quadrant in a twelve-month period for ages thirteen and
older, with prior authorization;
(l) Stainless steel crowns for primary
anterior teeth once every three years; if age thirteen and older with prior
authorization;
(m) Stainless steel
crowns for permanent posterior teeth once every three years;
(n) Metal/porcelain crowns and porcelain
crowns on anterior teeth only, with prior authorization;
(o) Space maintainers for missing primary
molars A, B, I, J, K, L, S, and T;
(p) One resin based partial denture, if
provided at least three years after the seat date;
(q) One complete denture upper and lower, and
one replacement denture per lifetime after at least five years from the seat
date;
(r) Rebasing and relining of
complete or partial dentures once in a three-year period, if performed at least
six months from the seat date.
(5) This section expires on December 31,
2016.
