f - 01c_Dental_Solicitation Att 3 Opt 2 Enhanced Plan Design_09.06.24.docx

Attachment (3) – Enhanced Plan Design (Increase: Calendar Year Maximum and Orthodontic Lifetime Maximum) PPO Option Plan Design

PPO BENEFITS SUMMARY

Class I: Diagnostic and Preventive Care and Emergency Care

· Oral exams; full-mouth, bitewing, panoramic and periapical x-rays

· Routine cleanings, fluoride application, sealants, space maintainers

· Palliative (emergency) treatment to relieve pain

100%

0%

100%

0%

Class II: Basic Restorative Care, Endodontics, Periodontics, Prosthodontics, Oral Surgery and Anesthesia

· Fillings

· Root canal therapy

· Osseous surgery, periodontal scaling and root planing

· Denture adjustments and repairs

· Extractions

· Anesthesia (deep sedation/general, IV moderate (conscious) sedation)

80%*

20%*

80%*

20%*

Class III**: Major Restorative Care, Implants and Prosthodontics

· Crowns, inlays and onlays

· Surgical implants, implant crowns

· Dentures, bridges, and partials

60%*

40%*

60%*

40%*

Class IV – Orthodontia

· Coverage for children and adults

60%

40%

60%

40%

Calendar Year Maximum (January 1 – December 31) Class I, II and III services

$3,000

Calendar Year Deductible (January 1 – December 31) Individual Family

$50 per person $150 per family

*Subject to annual deductible ** Missing Tooth Limitation – Replacement of a missing tooth is covered under Class III benefits; however, a 24-month coverage limitation exists when it replaces a tooth extracted or otherwise missing prior to the effective date of coverage. For replacement of a missing tooth within 24 months of enrollment, the plan pays at 30%, and you will pay 70%. For 25 months and beyond, the plan pays at 60%, and you will pay 40%.

PPO PLAN DETAILS BY PROCEDURE CODES

PPO Procedure Code Details Covered Procedures

% Paid In-Network: I00% for Diagnostic & Preventive Services 80% for Basic Restorative Services 60% for Major Restorative, Endodontic, Periodontal, Oral Surgery and Prosthodontic Services % Paid Out-of-Network: I00% for Diagnostic & Preventive Services 80% for Basic Restorative Services 60% for Major Restorative, Endodontic, Periodontal, Oral Surgery, Prosthodontic Services, and Orthodontics Annual Maximum: $2,500 Annual Deductible: $50, waived for Diagnostic & Preventive Services $150 maximum per family per calendar year Lifetime Maximum for Ortho: $2,000

Class I Diagnostic Services

Class I Preventive Services

Adjunctive General Services

D9110 Palliative treatment of dental pain per visit

Class II Basic Restorative Services

Class II Endodontic Services

Class II Periodontic Services

tooth bounded spaces per quadrant

diagnosis on subsequent visit

Class II Prosthodontic Services - Removable

Class II Prosthodontic Services - Fixed

D6980 Fixed partial denture repair necessitated by restorative material failure, by report

Class II Oral Surgery Services

and including elevation of mucoperiosteal flap if indicated

Class II Adjunctive General Services

Class III Diagnostic Services

D0160 Detailed and extensive oral evaluation – problem focused, by report

Class III Major Restorative Services

D2630 Inlay – porcelain/ceramic – three or more surfaces D2644 Onlay – porcelain/ceramic – four or more surfaces D2740 Crown – porcelain/ceramic D2750 Crown – porcelain fused to high noble metal

Class III Implants

Class III Prosthodontic Services - Removable

Class III Prosthodontic Services - Fixed

D6751 Retainer crown – porcelain fused to predominantly base metal D6753 Retainer crown – porcelain fused to titanium or titanium alloys D6752 Retainer crown – porcelain fused to noble metal D6780 Retainer crown – ¾ cast high noble metal

Class III Adjunctive General Services

Class IV Orthodontic Services

Alternate Benefit

Limitations

Policy Limitations for Diagnostic Services (Class I Services)

1. Two oral evaluations (D0120, D0150 and D0180) are covered in a calendar year. A comprehensive periodontal evaluation will be considered integral if provided on the same date of service by the same dentist as any other oral evaluation.

2. Only one comprehensive evaluation (D0150) will be allowed in a calendar year.

3. Only one limited oral evaluation, problem-focused (D0140) will be allowed per patient per dentist in a 12-month period. A limited oral evaluation will be considered integral when provided on the same date of service by the same dentist as any other oral evaluation.

4. Re-evaluations are considered integral to the originally performed procedures.

5. A full-mouth series (complete series) of radiographic images includes bitewings. Any additional radiographic image taken with a complete radiographic image series is considered integral to the complete series.

6. If the individually listed radiographs equals or exceeds a complete series, these radiographs are paid as a complete series and are subject to the same benefit limitations

7. Payment for more than one of any category of full-mouth radiographic images within a 48-month period is the patient’s responsibility. If a full-mouth series (complete series) is denied because of the 48-month limitation, it cannot be reprocessed and paid as bitewings and/or additional radiographic images.

8. Payment for panoramic radiographic images is limited to one within a 48-month period.

9. Payment for periapical radiographic images (other than as part of a complete series) is limited to four within a 12-month period except when done in conjunction with emergency services and submitted by report.

10. Payment for a bitewing survey, whether single, two, three, four or vertical radiographic image(s), including those taken as part of a complete series, is limited to one within a 12-month period.

11. Radiographic images of non-diagnostic quality are not payable.

12. Test reports must describe the pathological condition, type of study and rationale.

Policy Limitations for Preventive Services (Class I Services)

1. Two routine prophylaxes are covered in a calendar year.

2. Routine prophylaxes are considered integral when performed by the same dentist on the same day as scaling and root planing, periodontal surgery and periodontal maintenance procedures.

3. Routine prophylaxes are considered integral when performed in conjunction with or as a finishing procedure to periodontal scaling and root planning, periodontal maintenance, gingivectomies or gingivoplasties, gingival flap procedures, mucogingival surgery, or osseous surgery.

4. Routine prophylaxis includes associated scaling and polishing procedures. There are no provisions for any additional allowance based on degree of difficulty.

5. Periodontal scaling in the presence of gingival inflammation is considered to be a routine prophylaxis and paid as such. Participating dentists may not bill the patient for any difference in fees.

6. Two topical fluoride applications are covered in a calendar year period for children to age 19.

7. Space maintainers are only covered for dependent children under the age of 19.

8. Sealants are covered on permanent molars for children to age 19. The teeth must be caries free with no previous restorations on the mesial, distal or occlusal surfaces. One sealant per tooth is covered in a three-year period.

9. Sealants for teeth other than permanent molars are not covered.

10. Sealants provided on the same date of service and on the same tooth as a restorations of the occlusal surface are considered integral procedures.

Policy Limitations for Adjunctive General Services (Class I Services)

1. For palliative (emergency) treatment to be covered, it must involve a problem or symptom that occurred suddenly and unexpectedly and that requires immediate attention.

2. In order for palliative (emergency) treatment to be covered, the dentist must provide treatment to alleviate the patient’s problem. If the only service provided is to evaluate the patient and refer to another dentists and/or prescribe medication, the service would be considered a limited oral evaluation – problem-focused.

Policy Limitations for Basic Restorative Services (Class II Services)

1. Diagnostic casts (study models) taken in conjunction with restorative procedures are considered integral.

2. Sedative restorations are not a covered benefit.

3. Pin retention is covered only when reported in conjunction with an eligible restoration.

4. An amalgam or resin restoration reported with a pin (D2951) in addition to a crown is considered to be a pin buildup (D2950).

5. Preventive resin restorations or other restorations that do not extend into the dentin are considered sealants for purposes of determining benefits.

6. Repair or replacement of restorations by the same dentist and involving the same tooth surfaces performed within 24 months of the original restoration are considered integral procedures, and a separate fee is not chargeable to the member by a participating dentists. However, payment may be allowed if the repair or replacement is due to fracture of the tooth or the restorations involves the occlusal surface of a posterior tooth or the lingual surface of an anterior tooth and is placed following root canal therapy.

7. Restorations are not covered when performed after the placement of any type of crown or inlay/onlay, on the same tooth and by the same dentist.

8. The payment for restorations includes all related services to include, but not limited to, etching, bases, liners, dental adhesives, local anesthesia, polishing, caries removal, preparation of gingival tissue, occlusal/contact adjustments, and detection agents.

9. Prefabricated stainless steel crowns (D2930, D2931) are covered only on primary teeth, permanent teeth through age 14, or when placed as a result of accidental injury. They are limited to one per tooth, per lifetime.

10. Re-cementation of prefabricated and cast crowns, bridges, onlays, inlays, and posts is eligible once per dental office. Re-cementation provided within 6 months of placement by the same dentist is considered integral.

Policy Limitations for Endodontic Services (Class II Services)

1. Pulpotomies are considered integral when performed by the same dentist within a 45- day period prior to the completion of root canal therapy.

2. A pulpotomy is covered when performed as a final endodontic procedure and ispayable on primary teeth only. Pulpotomies performed on permanent teeth are considered integral to root canal therapy and are not reimbursable unless specific rationale is provided and root canal therapy is not and will not be provided on the same tooth.

3. Pulpal therapy (resorbable filling) is limited to primary teeth only. It is a benefit for primary incisor teeth for patients up to age six and for primary molars and cuspids to age 11 and is limited to once per tooth per lifetime. Payment for the pulpal therapy will be offset by the allowance for a pulpotomy provided within 45 days preceding pulpal therapy on the same tooth by the same dentist.

4. Treatment of a root canal obstruction is considered an integral procedure.

5. Incomplete endodontic therapy is not a covered benefit when due to the patient discontinuing treatment.

6. For reporting and benefit purposes, the completion date for endodontic therapy is the date the tooth is sealed.

7. Placement of a final restoration following endodontic therapy is eligible as a separate procedure.

Policy Limitations for Periodontal Services (Class II Services)

1. Gingivectomy or gingivoplasty, gingival flap procedure, guided tissue regeneration, soft tissue grafts, bone replacement grafts and osseous surgery provided within 36 months of the same surgical periodontal procedure in the same area of the mouth are not covered.

2. Gingivectomy or gingivoplasty performed in conjunction with the placement of crowns, inlays, onlays, crown buildups, posts and cores or basic restorations are considered integral to the restoration.

3. Surgical periodontal procedures in the same area of the mouth within 36 months of a gingival flap procedure are not covered.

4. Gingival flap procedure is considered integral when provided on the same date of service by the same dentist in the same area of the mouth as periodontal surgical procedures, endodontic procedures and oral surgery procedures.

5. Subepithelial connective tissue grafts and combined connective tissue and double pedicle grafts are payable at the level of free soft tissue grafts. The difference between the allowance for the soft tissue graft and the dentist’s charge is the patient’s responsibility.

6. A single site for reporting osseous grafts consists of one contiguous area, regardless of the number of teeth (e.g., crater) or surfaces involved. Another site on the same tooth is considered integral to the first site reported. Non-contiguous areas involving different teeth may be reported as additional sites.

7. Osseous surgery is not covered when provided within 36 months of osseous surgery in the same area of the mouth.

8. Osseous surgery performed in a limited area and in conjunction with crown lengthening on the same date of service by the same dentist and in the same area of the mouth will be processed as crown lengthening.

9. Guided tissue regeneration is covered only when provided to treat Class II furcation involvement or interbony defects. It is not covered when provided to obtain root coverage or when provided in conjunction with extractions, cyst removal or procedures involving the removal of a portion of a tooth, e.g., apicoectomy or hemisection.

10. One crown lengthening per tooth per lifetime is covered.

11. Periodontal scaling and root planing provided within 24 months of periodontal scaling and root planning or periodontal surgical procedures in the same area of the mouth are not covered.

12. A routine prophylaxis is considered integral when performed in conjunction with or as a finishing procedure to periodontal scaling and root planing, periodontal maintenance, gingivectomy or gingivoplasty, gingival flap procedure or osseous surgery.

13. Up to four periodontal maintenance procedures and up to two routine prophylaxes may be paid within calendar year, but the total of periodontal maintenance and routine prophylaxes may not exceed four procedures in a 12-month period.

14. Periodontal maintenance is only covered when performed following active periodontal treatment.

15. An oral evaluation reported in addition to periodontal maintenance will be processed as a separate procedure subject to the policy and limitations applicable to oral evaluations.

16. Payment for multiple periodontal surgical procedures (except soft tissue grafts, osseous grafts, and guided tissue regeneration) provided in the same area of the mouth during the same course of treatment is based on the fee for the greater surgical procedure. The lesser procedure is considered integral and its allowance is included in the allowance for the greater procedure.

17. Surgical revision procedure (D4268) is considered integral to all other periodontal procedures.

18. Full mouth debridement to enable comprehensive evaluation and diagnosis (D4355) is covered once per lifetime.

19. Bone grafts and guided tissue regeneration must be submitted with documentation. These procedures are payable only for treatment of functional teeth with a reasonable prognosis. These procedures are not a covered benefit when performed in connection with ridge augmentation, apicoectomies, extractions, implants or other non- periodontal surgical procedures.

20. Periodontal soft tissue grafts require a narrative report documenting the diagnosis and necessity for the procedure.

21. Up to two tissue grafts are payable per quadrant per visit. Additional tissue grafts performed in a quadrant are not covered benefits.

22. Localized delivery of antimicrobial agents via a controlled release vehicle is not a covered benefit when provided in conjunction with scaling and root planing.

Policy Limitations for Oral Surgery Services (Class II Services)

1. Simple incision and drainage reported with root canal therapy is considered integral to the root canal therapy.

2. Intraoral soft tissue incision and drainage is only covered when it is provided as the definitive treatment of an abscess. Routine follow-up care is considered integral to the procedure.

3. Charges for related services such as necessary wires and splints, adjustments, and follow-up visits are considered integral to the fee for reimplantation and/or stabilization.

4. Routine postoperative care such as suture removal is considered integral to the fee for the surgery.

5. The removal of impacted teeth is paid based on the anatomical position as determined from a review of x-rays. If the degree of impaction is determined to be less than the reported degree, payment will be based on the allowance for the lesser level.

6. Removal of impacted third molars in patients under age 15 and over age 30 is not covered unless specific documentation is provided that substantiates the need for removal.

7. Laboratory charges for histopathologic examinations/evaluations (D0501) are not covered. Biopsies are defined as the surgical removal of tissues specifically for histopathologic examination/evaluation. Removal of tissues during other procedures (such as extractions and apicoectomies) is not payable as a biopsy.

8. The fee for frenulectomy is included when billed on the same date as any other surgical procedure(s) in the same surgical area by the same dentist.

Policy Limitations for Adjunctive General Services (Class II Services)

1. Deep sedation/general anesthesia and intravenous conscious sedation are covered (by report) only when provided in connection with a covered surgical procedure(s) and when rendered by a dentist or other professional provider licensed and approved to provide anesthesia in the state where the service is rendered.

2. Deep sedation/general anesthesia and intravenous conscious sedation are covered only by report when determined to be medically or dentally necessary for documented handicapped or uncontrollable patients or justifiable medical or dental conditions.

3. In order for deep sedation/general anesthesia and intravenous conscious sedation to be covered, the procedure for which it was provided must be submitted and approved.

4. Deep sedation/general anesthesia and intravenous conscious sedation submitted without a report will be denied as a non-covered benefit.

Policy Limitations for Diagnostic Services (Class III Services)

1. Detailed and extensive oral evaluations (D0160) are limited to once per patient per dental office.

Policy Limitations for Major Restorative Services (Class III Services)

1. The charge for a crown or inlay/onlay should include all charges for work related to its placement to include, but not limited to, preparation of gingival tissue, tooth preparation, temporary crown, diagnostic casts (study models), impressions, try-in visits, and cementations of both temporary and permanent crowns.

2. Inlays, onlays, permanent single crown restorations, and posts and cores for patients 12 years of age or younger are excluded from coverage, unless specific rationale is provided indicated the reason for such treatment (e.g., fracture, endodontic therapy, etc.).

3. Core buildups (D2950) can be considered for benefits only when there is insufficient retention for a crown. A buildup should not be reported when the procedure only involves a filler used to eliminate undercuts, box forms or concave irregularities in the preparation.

4. Cast posts and cores (D2952) are processed as an alternative benefit of a prefabricated post and core. The patient is responsible for the difference between the dentist’s charge for the cast post and core and the amount paid for the prefabricated post and core.

5. Re-cementation of prefabricated and cast crowns, bridges, onlays, inlays, and posts is eligible once per dental office. Re-cementation provided within 6 months of placement by the same dentist is considered integral.

6. Replacement of crowns, inlays, onlays, buildups, and posts and cores is covered only if the existing crown, inlay, onlay, buildup or post and core was inserted at least five years prior to the replacement and satisfactory evidence is presented that the existing crown, inlay, onlay, buildup or post and core is not and cannot be made serviceable. The five-year service date is measured based on the actual date (day and month) of the initial service versus the first day of the initial service month.

7. Inlays, onlays, crowns, and posts and cores are payable only when necessary due to decay or tooth fracture. However, if the tooth can be adequately restored with amalgam or composite (resin) filling material, payment will be made for that service. This payment can be applied toward the cost of the inlay, onlay, crown, or post and core.

8. Crowns, inlays, onlays, buildups, or posts and cores begun prior to the effective date of coverage or cemented after the cancellation date of coverage are not eligible for payment.

9. When performed as an independent procedure, the placement of a post is not a covered benefit. Posts are only eligible when provided as part of a buildup for a crown or implant and are considered integral to the buildup or implant.

10. Payment for a resin restoration will be made when a laboratory-fabricated porcelain or resin veneer is used to restore any teeth due to tooth fracture or caries.

11. Replacement of a missing tooth is covered under Class III benefits; however, a 24-month coverage limitation exists when it replaces a tooth extracted or otherwise missing prior to the effective date of coverage. For replacement of a missing tooth within 24 months of enrollment, the plan pays at 30%, and you will pay 70%. For 25 months and beyond, the plan pays at 60%, and you will pay 40%.

Policy Limitations for Implant Services (Class III Services)

1. Implant services are not eligible for patients under 14 unless submitted with x-rays and approved by Delta Dental.

2. Implants may not be covered when placed for a removable denture.

3. Replacement of implants is covered only if the existing implant was placed at least five years prior to the replacement and the implant has failed.

4. Replacement of an implant prosthesis is covered only if the existing prosthesis was placed at least five years prior to the replacement and satisfactory evidence presented that demonstrates that it is not, and cannot be made, serviceable.

5. Repair of an implant-supported prosthesis (D6090), repair of an implant abutment (D6095), and removal of broken implant retaining screw (D6096) are only payable by report upon Delta Dental dentist advisor review and is only payable once in five years. The report should describe the problem and how it was repaired.

6. Replacement of a missing tooth is covered under Class III benefits; however, a 24-month coverage limitation exists when it replaces a tooth extracted or otherwise missing prior to to the effective date of coverage. For replacement of a missing tooth within 24 months of enrollment, the plan pays at 30%, and you will pay 70%. For 25 months and beyond, the plan pays at 60%, and you will pay 40%.

Policy Limitations for Prosthodontic Services (Class III Services)

1. For reporting and benefit purposes, the completion date for crowns and fixed partial dentures is the cementation date. The completion date is the insertion date for removable prosthodontic appliances. For immediate dentures, however, the provider who fabricated the dentures may be reimbursed for the dentures after insertion if another provider, typically an oral surgeon, inserted the dentures.

2. The fee for diagnostic casts (study models) fabricated in conjunction with prosthetic and restorative procedures are included in the fee for these procedures. A separate fee is not chargeable to the member by a participating dentist.

3. Tissue conditioning is considered integral when performed on the same day as the delivery of a denture or a reline/rebase.

4. Recementation of cast crowns, fixed partial dentures, inlays, onlays, or cast posts within six months of their placement by the same dentist is considered integral to the original procedure.

5. Adjustments provided within six months of the insertion of an initial or replacement denture or implant are integral to the denture or implant.

6. The relining or rebasing of a denture is considered integral when performed within six months following the insertion of that denture.

7. A reline/rebase is covered once in any 36 months.

8. Fixed partial dentures, buildups, and posts and cores for members under 16 years of age are not covered unless specific rationale is provided indicating the necessity for such treatment.

9. Payment for a denture or an overdenture made with precious metals is based on the allowance for a conventional denture. Specialized procedures performed in conjunction with an overdenture are not covered. Any additional cost is the patient’s responsibility.

10. A fixed partial denture and removable partial denture are not covered benefits in the same arch. Payment will be made for a removable partial denture to replace all missing teeth in the arch.

11. Precision attachments, personalization, precious metal bases, and other specialized techniques are not covered benefits.

12. Temporary fixed partial dentures are not a covered benefits and, when done in conjunction with permanent fixed partial dentures, are considered integral to the allowance for the fixed partial dentures.

13. Implants and related prosthetics may be covered and may be reimbursed as an alternative benefit as a three-unit fixed partial denture.

14. Replacement of removable prostheses and fixed prostheses is covered only if the existing removable and/or fixed prostheses were inserted at least five years prior to the replacement and satisfactory evidence is presented that the existing removable and/or fixed prostheses cannot be made serviceable. The five-year service date is measured based on the actual date (day and month) of the initial service versus the first day of the initial service month.

15. Replacement of dentures that have been lost, stolen, or misplaced is not a covered service.

16. Removable or fixed prostheses initial prior to the effective date of coverage or inserted/cemented after the cancellation date of coverage are not eligible for payment.

17. Replacement of a missing tooth is covered under Class III benefits; however, a 24-month coverage limitation exists when it replaces a tooth extracted or otherwise missing prior to the effective date of coverage. For replacement of a missing tooth within 24 months of enrollment, the plan pays at 30%, and you will pay 70%. For 25 months and beyond, the plan pays at 60%, and you will pay 40%.

Policy Limitations for Adjunctive General Services (Class III Services)

1. Consultations are covered only when provided by a dentist other than the practitioner providing the treatment.

2. Consultations reported for a non-covered benefit, such as temporomandibular joint dysfunction (TMJD), are not covered.

3. After-hours visits are covered only when the dentist must return to the office after regularly scheduled hours to treat the patient in an emergency situation.

4. Therapeutic drug injections are only payable in unusual circumstances, which must be documented by report.