Schedule J Plan Design with Procedure Codes.xlsx

This is a Schedule J Plan Design document for the State of Michigan RFP No. 200000001290, detailing dental health plan coverage specifications and benefit structures. The plan establishes a comprehensive dental benefits framework covering diagnostic and preventative services, basic restorative procedures, major services, endodontic and periodontic treatments, prosthodontics, and orthodontic services for eligible persons. The plan design specifies differentiated coverage levels between in-network and out-of-network providers, with in-network defined as the plan sponsor's deepest discount network and all other networks classified as out-of-network.

The plan establishes specific coinsurance percentages for each service category, with diagnostic and preventative services covered at 95 percent in-network and 90 percent out-of-network with no deductible, while basic and major services range from 75 to 80 percent coinsurance depending on service type. Prosthodontic and orthodontic services are covered at 50 percent coinsurance with a $1,200 lifetime maximum per eligible person for orthodontics and a $1,100 per person annual maximum for diagnostic, preventative, basic, and major services combined. The document provides an extensive procedure code matrix covering codes D0120 through D9999, specifying coverage status (covered, not covered, or optional) and coinsurance percentages for each individual dental procedure code, with the plan sponsor's liability for out-of-network services calculated based on the in-network fee schedule, allowing participating out-of-network providers to charge members the difference between schedules without balance billing.