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Pediatric Dental Essential Health Benefits
We value your participation in our Preferred Dentist Program network and the care you provide our members. We would like to share the following information about essential health benefits with you.
Pediatric dental coverage is one of the 10 Affordable Care Act (ACA) essential health benefits required for plans offered on the health insurance marketplace for individuals or the Small Business Health Options Program (SHOP) for small employers (two to 50 employees) providing insurance to their employees. Pediatric dental benefits are available for children up to the end of the month in which a member turns 19. Please request the member's medical and dental ID cards in order to verify pediatric dental benefits. When checking eligibility and benefits through your practice management software or ProviderAccess, the following information will display:
Dental: In-Network pediatric dental services apply to the health deductible and out-of-pocket.
Medical: In-Network pediatric dental services apply to the health deductible and out-of-pocket.
All plans include benefits for pediatric eye exams; glasses; diagnostic and preventive dental services; and basic (e.g., fillings, simple tooth extractions, non-surgical root canal), major (e.g., oral surgery, general anesthesia, periodontic exams) and orthodontic services (must be medically necessary orthodontic services). Medically necessary pediatric orthodontic services are defined as follows:
Dentally necessary orthodontia is covered for the treatment of congenital or hereditary conditions which result in craniofacial abnormalities that would require medically necessary surgical correction (as determined by the plan) due to problems related to swallowing, chewing, speaking, breathing, or for acute injury to the teeth from an external force which cannot be stabilized by any other method. This treatment may be performed prior to and/or following the corrective surgery. Dentally necessary orthodontia, as defined by this plan, does not include realigning teeth, closing gaps between teeth, or the movement of teeth for cosmetic purposes.In addition to the health plan’s pediatric dental coverage, a member can also enroll in a stand-alone dental plan. For coordination of benefits, normal coordination of benefits rules apply for pediatric dental coverage. However, in most instances, the pediatric dental coverage is the primary coverage over a stand-alone dental plan.