Healthy FamiliesDental Benefits and Copayments

Section § 12693.63

Explanation

This law outlines the dental benefits for subscribers under a specific program. It states that dental benefits should match those provided to state employees in 1997, but orthodontia is only covered if deemed medically necessary.

Subscribers will have copayments similar to those of state employees from 1997, with no copayments for necessary orthodontia, preventive, or diagnostic services like check-ups and cleanings. Subscribers also won't be charged deductibles for dental benefits.

Furthermore, the board can set a cap on dental coverage per year, which cannot be less than $1,500. They can create emergency regulations to implement these caps.

(a)CA Insurance Code § 12693.63(a) The board shall determine the dental benefits to be provided to subscribers by the program. These benefits shall be consistent with those provided to state employees through the Department of Personnel Administration, the predecessor to the Department of Human Resources, on July 1, 1997, except that orthodontia shall only be a benefit when it is determined to be medically necessary.
(b)CA Insurance Code § 12693.63(b) The board shall establish the required subscriber copayment levels for dental benefits. The copayment levels established by the board shall, to the extent possible, reflect the copayment levels provided to state employees through the Department of Personnel Administration, the predecessor to the Department of Human Resources, on July 1, 1997, except that no copayment shall be charged for medically necessary orthodontia services. There shall be no subscriber copayments for preventive and diagnostic services, including, but not limited to, examinations, teeth cleaning, X-rays, topical fluoride treatments, space maintainers, and sealants.
(c)CA Insurance Code § 12693.63(c) No deductible shall be charged to subscribers for dental benefits.
(d)Copy CA Insurance Code § 12693.63(d)
(1)Copy CA Insurance Code § 12693.63(d)(1) The board may establish a cap on the amount of dental coverage provided to a subscriber in a given benefit year effective on and after the first day of the fifth month following enactment of the 2008–09 Budget Act. This dental coverage cap shall not be lower than one thousand five hundred dollars ($1,500) per subscriber per benefit year.
(2)CA Insurance Code § 12693.63(d)(2) The board may adopt, and may only one-time readopt, regulations to implement paragraph (1). The adoption and one-time readoption of a regulation authorized by this paragraph is deemed to address an emergency, for purposes of Sections 11346.1 and 11349.6 of the Government Code, and the board is hereby exempted for this purpose from the requirements of subdivision (b) of Section 11346.1 of the Government Code.
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Section § 12693.64

Explanation

If a subscriber is eligible for the California Children’s Services Program, their participating health plan does not have to pay for or provide the specific services authorized by that program for treating the eligible medical condition. However, the subscriber can still access all other services the health plan offers.

Notwithstanding any other provision of law, for a subscriber who is determined by the California Children’s Services Program to be eligible for benefits under the program pursuant to Article 5 (commencing with Section 123800) of Chapter 3 of Part 2 of Division 106 of the Health and Safety Code, a participating plan shall not be responsible for the provision of, or payment for, the particular services authorized by the California Children’s Services Program for the particular subscriber for the treatment of a California Children’s Services Program eligible medical condition. All other services provided under the participating plan shall be available to the subscriber.
California Children’s Services Program eligible medical condition participating plan ...