Looking At Eligible And Ineligible Expenses

The DHMO covers a wide range of services, including those described below. If you want to know whether a particular service is covered, contact the Administrative Office or PMI Customer Relations.

Eligible Expenses From A To Z
The following is a list of most, but not all, covered services that you can receive after paying a copay:

DIAGNOSTIC AND PREVENTIVE BENEFITS
These benefits include:

• Comprehensive oral evaluation;
• Intraoral radiographs - complete series (including bitewings);
• Limited oral evaluation - problem-focused;
• Periodic oral evaluation;
• Prophylaxis (cleaning) - adult or child: 1 per 6-month period;
• Sealant, per tooth;
• Space maintainer - fixed - unilateral;
• Space maintainer - fixed - bilateral; and
• Topical application of fluoride, including prophylaxis (up to age 19) - 1 per 6-month period.

RESTORATIVE BENEFITS
Restorative benefits include:

• Amalgam - four or more surfaces, permanent;
• Amalgam - four or more surfaces, primary;
• Composite resin crown, anterior - primary; and
• Resin - four or more surfaces or involving incisal angle (anterior).

ORAL SURGERY BENEFITS
Oral surgery benefits include preoperative and postoperative evaluations and treatment under local anesthetic, as well as:

• Removal of impacted tooth - soft tissue;
• Root removal - exposed roots;
• Single tooth extraction/each additional; and
• Surgical removal of erupted tooth.

PERIODONTIC BENEFITS
Periodontic benefits include preoperative and postoperative evaluations and treatment under a local anesthetic, as well as gingivectomy or gingivoplasty, per quadrant.

PROSTHETIC BENEFITS (CROWNS, BRIDGES AND DENTURES)
Prosthetic benefits include:

• Crown - porcelain/ceramic 1;
• Crown - resin (laboratory);
• Denture - complete maxillary or mandibular (upper or lower);
• Inlay - three or more surfaces - base noble metal 2 ; and
• Onlay - four or more surfaces - base noble metal 2 .

1 Porcelain on molars is considered optional treatment.
2 Base noble metal is the benefit. High noble metal (precious), if used, will be charged to the enrollee at the additional laboratory cost of the high noble metal. This applies to crowns, bridges, cast and post cores, inlays and onlays.

ENDODONTIC BENEFITS
Endodontic benefits include:

• Pulp capping (direct/indirect);
• Root canal therapy - anterior (excluding final restoration);
• Root canal therapy - bicuspid (excluding final restoration);
• Root canal therapy - molar (excluding final restoration); and
• Therapeutic pulpotomy (excluding final restoration).

GENERAL SERVICES
Benefits for general services include:

• Local anesthesia; and
• Palliative (emergency) treatment of dental pain.

ORTHODONTIC BENEFITS
Orthodontic benefits are provided for:

• Adults (you, your covered spouse or your same-sex domestic partner) and covered full-time students age 23 and under; and
• Dependent children up to age 19.

Start-up fees (excluding records) are covered.

Plan Limitations
The following limitations apply to your DHMO coverage:

• Bitewing X-rays are limited to not more than one series of four films in any six-month period.
• Crown(s) and bridges are not to be replaced within any five-year period from initial placement.
• Denture relines are limited to one per denture during any 12 consecutive months.
• Full maxillary and/or mandibular dentures, including immediate dentures, are not to exceed one each in any five year period from initial placement.
• Full-mouth debridement (gross scale) is limited to one treatment during any 12 consecutive months.
• Full-mouth X-rays are limited to one set every 24 consecutive months.
• Partial dentures are not to be replaced within any five-year period from initial placement, unless necessary due to natural tooth loss where the addition or replacement of teeth to the existing partial is not feasible.
• Periodontal treatments (root planing/subgingival curettage) are limited to four quadrants during any 12 consecutive months.
• Prophylaxis treatment is cove red once every six months (includes periodontal maintenance following active therapy).
• Sealant benefits include the application of sealants only to permanent first and second molars with no decay, with no restorations and with the occlusal surface intact, for first molars up to age 9 and second molars up to age 14. Sealant benefits don't include the repair or replacement of a sealant on any tooth within three years of its application.

The DHMO provides coverage for orthodontic treatment plans when you see a DeltaCare network orthodontist. Your orthodontic benefits are subject to the following limitations:

• Orthodontic treatment must be provided by a DeltaCare orthodontist.
• The DHMO covers 24 months of orthodontic treatment.
• Should your coverage be canceled or terminated for any reason, and at the time of cancellation or termination you're receiving orthodontic treatment, you (and not DeltaCare) will be responsible for paying the balance due for treatment provided after cancellation or termination. In such a case, your payment will be based on a maximum of $2,300 for dependent children up to age 19 and $2,500 for covered full-time students and adults. The amount will be prorated over the number of months to completion of the treatment and will be payable on such terms and conditions as are arranged between you and the orthodontist. Start-up fees are included in these amounts.
• Start-up fees cover the initial examination, diagnosis, consultation and retention phase of treatment of up to two years. This includes initial construction, placement of retainers and adjustments to them, as well as office visits for a maximum period of two years.

Ineligible Expenses From A To Z
Although the DHMO covers a wide range of dental services, some services are not covered. It's important for you to know what these services are before you visit your dentist.

The DHMO doesn't cover the following services:

• Accidental injury, which is defined as damage to the hard and soft tissues of the oral cavity resulting from forces external to the mouth. Damages to the hard and soft tissues of the oral cavity from normal masticatory (i.e., chewing) function will be covered at the normal schedule of benefits;
• Any service that is not specifically listed as an eligible expense;
• Cases in which, in the professional judgment of the attending dentist, a satisfactory result cannot be obtained, or where the prognosis is poor or guarded;
• Congenital malformations (e.g., congenitally missing or supernumerary teeth);
• Cosmetic dental care;
• Crown lengthening procedures;
• Cysts and malignancies;
• Dental conditions arising out of and due to your employment or for which Workers' Compensation is payable;
• Dental expenses incurred in connection with any dental procedures started after eligibility for coverage has terminated;
• Dental services performed in a hospital and related hospital fees;
• Dental services received from any dental office other than the assigned DeltaCare office, unless expressly authorized in writing by DeltaCare or as cited under "Emergency Care";
• Dispensing of drugs not normally supplied in a dental office;
• General anesthesia and the services of a special anesthesiologist;
• Implant placement or removal, and appliances placed on or services associated with implants, including, but not limited to, prophylaxis and periodontal treatment;
• Loss or theft of fixed and removable prosthetics (e.g., crowns, bridges, full or partial dentures);
• Prophylactic removal of impactions (asymptomatic/nonpathological);
• Services that are provided by a state government agency or are provided without cost by any municipality, county or other subdivision, except as provided in Section 1373(a) of the California Health and Safety Code;
• "Specialist consultations" for ineligible expenses;
• Treatment of fractures and dislocations; and
• Treatment required by reason of war.

The following orthodontic services also are not covered:

• Lost, stolen or broken orthodontic appliances, functional appliances, headgear, retainers and expansion appliances;
• Pre-treatment, mid-treatment and post-treatment records, including cephalometric X-rays, tracings, photographs and study models;
• Retreatment of orthodontic cases;
• Treatment in progress when eligibility for coverage begins; and
• Transfer after banding has been initiated.

In addition, treatment that extends more than 24 months from the point of banding dentition will be subject to an office visit charge at the orthodontist's reasonable and customary fee.