Form CMS-10291 Insure Kids Now Children’s Dental Benefits Survey

Insure Kids Now Children’s Dental Benefits Survey – Electronic Form - 2014

State: Alaska

State: Alaska

Name of Program: MEDICAID

Program Package: Medicaid

Children's Dental Services	Is The Service Covered?			Frequency (Specify periodicity)	List Any Service-specific Limitations (eg. age limits, tooth-specific limits, or a cost or dollar threshold above which prior authorization is required)	Criteria for Coverage
	Yes	Only With Prior Authorization	No
I. Preventive Services
A. Cleanings
B. Fluoride treatments (including fluoride varnishes)
C. Sealants (list any tooth-specific limits)
D. Space maintainers
II. Diagnostic Services
A. Dental examinations						Recommended age of visit?
B. X-Rays
i. Bitewing
ii. Full Mouth
iii. Panoramic
III. Treatment Services
A. Fillings
i. Silver amalgam
ii. Tooth colored composite
B. Crowns/tooth caps
i. Stainless steel crowns
ii. Metal (only) crowns
iii. Metal/porcelain crowns
iv. Porcelain (only) crowns
C. Root Canals (endodontics)
i. Root canals on baby teeth (pulpotomies)
ii. Root canals on permanent teeth
D. Gum (periodontal) therapy
E. Dentures
i. Partial dentures
ii. Complete dentures
iii. Bridges
F. Orthodontics*
i. Retainers (orthodontic)
ii. Braces
G. Oral surgery
i. Simple extractions
ii. Surgical extractions
iii. Care of abscesses
iv. Cleft palate treatment
v. Cancer treatment
vi. Treatment of fractures
vii. Biopsies
H. Treatment of jaw joint problems (TMJ)
I. Emergency room services provided by a dentist
J. Inpatient Hospital Services
K. Anesthesia
i. General anesthesia
ii. Intravenous conscious sedation
iii. Non-intravenous conscious sedation
iv. Analgesia (nitrous oxide)

Is Form Completed?

* When this information is posted on the Insure Kids Now website, we will include a special note for orthodontic services explaining that parents and caretakers should work with their child's orthodontist to ensure that the treatment and payment terms and conditions are clear at the outset of treatment (for example, what happens in the case of a child who becomes ineligible for Medicaid or CHIP while he or she is undergoing orthodontic treatment?).

If applicable, please provide the amount of the annual cost or funding level above which prior authorization is required. If the State requires that certain services only be provided with prior authorization, please list the categories of services to which this would apply.

Please verify that the information on your State's cost sharing requirements are correct as posted on the Insure Kids Now! website www.insurekidsnow.gov. If the information is not correct, please correct it at this time.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1065. The time required to complete this information collection is estimated to average 40 quarterly hours and 30 hours annually per response, including the time to review instructions, search existing data resources, gather the data needed, and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to CMS, 7500 Security Boulevard, Attn” PRA Reports Clearance Officer, Mails Stop C4-26-05, Baltimore, Maryland 21244-1850.