Benchmark plan Recementations of permanent indirect crowns for enrollees 12 years of age and older; Benchmark plan Dental implant crown and abutment related procedures, one per enrollee per tooth in a seven-year period. Benchmark plan Adjustment and repair of dentures and bridges; Benefits need not be provided for adjustments or repairs done within one year of insertion. Benchmark plan Repair of crowns. May be limited to one per tooth per enrollee Crown and Required lifetime. fixed bridge Coverage Benchmark plan Repair of implant-supported prosthesis or abutment. May be (Cont’d) (Cont’d) limited to one per per enrollee lifetime. Diagnostic Required WAC Must cover diagnostic services in a manner substantially equal to the Services Diagnostic See, also, base-benchmark plan. This must include, at least, the following WAC Services 284-43-5702(6). that services, which must be covered without cost sharing (as they are Must be covered as preventive services under the base benchmark plan): Provided WAC Diagnostic exams once every six months, beginning before one year of age;
Crown and fixed bridge (Cont’d) Required Coverage (Cont’d) Benchmark plan Recementations of permanent indirect crowns for enrollees 12 years of age and older; Benchmark plan Dental implant crown and abutment related procedures, one per enrollee per tooth in a seven-year period. Benchmark plan Adjustment and repair of dentures and bridges; Benefits need not be provided for adjustments or repairs done within one year of insertion. Benchmark plan Repair of crowns. May be limited to one per tooth per enrollee lifetime. Benchmark plan Repair of implant-supported prosthesis or abutment. May be limited to one per per enrollee lifetime. Diagnostic Services Required Diagnostic Services that Must be Provided WAC See, also, WAC 284-43-5702(6). Must cover diagnostic services in a manner substantially equal to the base-benchmark plan. This must include, at least, the following services, which must be covered without cost sharing (as they are covered as preventive services under the base benchmark plan): WAC Diagnostic exams once every six months, beginning before one year of age;
cklist-forms-2018-hcsc-sg-stand-alone-dental-w-pediatric-ehbs.docx