Form CMS-10288 SPA Template Addendum on Dental Benefits Under Title XXI

Draft

Draft SPA Template: Addendum on Dental Benefits Under Title XXI

Section 6. Coverage Requirements for Children’s Health Insurance (Section 2103)

6.2.-D The State will provide dental coverage to children through one of the following. Dental services provided to children eligible for dental-only supplemental services must receive the same dental services as provided to otherwise eligible CHIP children (Section 2103(a)(5)):

6.2.1.-D  State Specific Dental Benefit Package. The State assures dental services represented by the following categories of common dental terminology (CDT) codes are included in the dental benefits:

1. Diagnostic (CDT codes: D0100-D0999) (must follow periodicity schedule)

2. Preventive (CDT codes: D1110-D1206) (must follow periodicity schedule)

3. Restorative (CDT codes: D2000-D2999)

4. Endodontic (CDT codes: D3000-D3999)

5. Periodontic (CDT codes: D4000-D4999)

6. Prosthodontic (CDT codes: D5000-5899 and D5900-D5999 and D6200-D6999)

7. Oral and Maxillofacial Surgery (CDT codes: D7000-D7999)

8. Orthodontics (CDT codes: D8000-D8999)

9. Emergency Dental Services

6.2.1.2-D Periodicity Schedule. Please select and include a description.  Medicaid

 American Academy of Pediatric Dentistry

 Other Nationally recognized periodicity schedule: (Please

Specify and attach a copy)

6.2.2-D  Benchmark coverage; (Section 2103(c)(5), 42 CFR 457.410, and 42 CFR 457.420)

6.2.2.1.-D  FEHBP‑equivalent coverage; (Section 2103(c)(5)(C)(i))

(If checked, attach copy of the dental supplemental plan benefits description and the applicable CDT codes. If the State chooses to provide additional services to those in the benchmark, please attach a description of the services and applicable CDT codes)

6.2.2.2-D  State employee coverage; (Section 2103(c)(5)(C)(ii)) (If checked, identify the plan and attach a copy of the benefits description and the applicable CDT codes. If the State chooses to provide additional services to those in the benchmark, please attach a description of the services and applicable CDT codes)

6.2.2.3.-D  HMO with largest insured commercial enrollment (Section 2103(c)(5)(C)(iii)) (If checked, identify the plan and attach a copy of the benefits description and the applicable CDT codes. If the State chooses to provide additional services to those in the benchmark, please attach a description of the services and applicable CDT codes)

Section 10. Annual Reports and Evaluations

Section 10.3-D  Specify that the State agrees to submit yearly the approved dental benefit package and to submit quarterly the required information on dental providers in the State to the Health Resources and Services Administration for posting on the Insure Kids Now! Web site.

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