Benchmark plan Repair of implant-supported prosthesis or abutment. May be limited to one per tooth per enrollee lifetime. Crown and fixed bridge (Cont’d) Diagnostic WAC Required Must cover diagnostic services in a manner substantially equal to the Services Diagnostic See, base-benchmark plan. This must include, at least, the following also, Services WAC services, which must be covered without cost sharing (as they are covered as preventive services under the base benchmark plan): Diagnostic Required WAC Diagnostic exams once every six months, beginning before one Services Diagnostic year of age; (Cont’d) Services that WAC Limited oral evaluations when necessary to evaluate for a specific Must be dental problem or oral health complaint, dental emergency or Provided referral for other treatment; Without Cost WAC Limited visual oral assessments or screenings, limited to two per Sharing member per calendar year, not performed in conjunction with (Cont’d) other clinical oral evaluation services; Benchmark Plan Problem focused oral examinations; WAC Two sets of bitewing X rays per member per year for a total of four bitewing X rays per member per year; (5)(d) Cephalometric films once in a two-year period; WAC Panoramic X rays (complete intraoral mouth X rays) once every three years; Benchmark Plan Complete intraoral mouth X rays once every three years;
Crown and fixed bridge (Cont’d) Benchmark plan Repair of implant-supported prosthesis or abutment. May be limited to one per tooth per enrollee lifetime. Diagnostic Services Diagnostic Services (Cont’d) Required Diagnostic Services Required Diagnostic Services that Must be Provided Without Cost Sharing (Cont’d) WAC See, also, WAC 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; WAC Limited oral evaluations when necessary to evaluate for a specific dental problem or oral health complaint, dental emergency or referral for other treatment; WAC Limited visual oral assessments or screenings, limited to two per member per calendar year, not performed in conjunction with other clinical oral evaluation services; Benchmark Plan Problem focused oral examinations; WAC Two sets of bitewing X rays per member per year for a total of four bitewing X rays per member per year; (5)(d) Cephalometric films once in a two-year period; WAC Panoramic X rays (complete intraoral mouth X rays) once every three years; Benchmark Plan Complete intraoral mouth X rays once every three years;
cklist-forms-18-hcsc-ind-stand-alone-dental-w-pediatric-ehbs.docx