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

Summary of Benefits Form:

Program Type:

State:

MEDICAID

Alabama

As a convenience for state users, summary of benefits information entered on this form is pre-populated
based on the most recent submission. Also, please note that in order to ensure the information on the
public website remains current and relevant, the information on these forms will be cleared if no update
has been submitted in more than two years

*I. Preventive Services
Children’s
Dental
Service

*A.
Cleanings

Is the
Service
Covered
(Yes)

Is the Service
Covered
(Only with
Prior
Authorization

Is the
Service
Covered
(No)

Frequency
(Specify
periodicity)
Please
select from
the
following:

1x2
months
1x3
months
1x5
months
1x6
months
1 x year
2 x year
3 x year
Up to 4 x
year
1 x every 2
years
1 x every 3
years

List Any
Servicespecific
Limitations
(eg. age limits,
tooth-specific
limits,
or a cost or
dollar
threshold
above which
prior
authorization
is required)

Criteria
for
Coverage

Children’s
Dental
Service

*B. Fluoride
treatments
(including
fluoride
varnishes)

*C.
Sealants
(list any
toothspecific
limits)

Is the
Service
Covered
(Yes)

Is the Service
Covered
(Only with
Prior
Authorization

Is the
Service
Covered
(No)

Frequency
(Specify
periodicity)
Please
select from
the
following:

1 x every 4
years
1 x every 5
years
1 x lifetime
1x2
months
1x3
months
1x5
months
1x6
months
1 x year
2 x year
3 x year
Up to 4 x
year
1 x every 2
years
1 x every 3
years
1 x every 4
years
1 x every 5
years
1 x lifetime
1x2
months
1x3
months
1x5
months

List Any
Servicespecific
Limitations
(eg. age limits,
tooth-specific
limits,
or a cost or
dollar
threshold
above which
prior
authorization
is required)

Criteria
for
Coverage

Children’s
Dental
Service

*D. Space
maintainers

Is the
Service
Covered
(Yes)

Is the Service
Covered
(Only with
Prior
Authorization

Is the
Service
Covered
(No)

Frequency
(Specify
periodicity)
Please
select from
the
following:

1x6
months
1 x year
2 x year
3 x year
Up to 4 x
year
1 x every 2
years
1 x every 3
years
1 x every 4
years
1 x every 5
years
1 x lifetime
1x2
months
1x3
months
1x5
months
1x6
months
1 x year
2 x year
3 x year
Up to 4 x
year
1 x every 2
years
1 x every 3
years

List Any
Servicespecific
Limitations
(eg. age limits,
tooth-specific
limits,
or a cost or
dollar
threshold
above which
prior
authorization
is required)

Criteria
for
Coverage

Children’s
Dental
Service

Is the
Service
Covered
(Yes)

Is the Service
Covered
(Only with
Prior
Authorization

Is the
Service
Covered
(No)

Frequency
(Specify
periodicity)
Please
select from
the
following:

1 x every 4
years
1 x every 5
years
1 x lifetime

List Any
Servicespecific
Limitations
(eg. age limits,
tooth-specific
limits,
or a cost or
dollar
threshold
above which
prior
authorization
is required)

Criteria
for
Coverage

*II. Diagnostic Services
Children’s
Dental
Service

*A. Oral
health
screening or
assessment

Is the
Service
Covered
(Yes)

Is the Service
Covered
(Only with
Prior
Authorization

Is the
Service
Covered
(No)

Frequency
(Specify
periodicity)
Please
select from
the
following:

1x2
months
1x3
months
1x5
months
1x6
months
1 x year
2 x year

List Any
Criteria for
ServiceCoverage
specific
Limitations
(eg. age
limits, toothspecific
limits,
or a cost or
dollar
threshold
above which
prior
authorization
is required)

Children’s
Dental
Service

*B. Dental
examinations

Is the
Service
Covered
(Yes)

Is the Service
Covered
(Only with
Prior
Authorization

Is the
Service
Covered
(No)

Frequency
(Specify
periodicity)
Please
select from
the
following:

3 x year
Up to 4 x
year
1 x every 2
years
1 x every 3
years
1 x every 4
years
1 x every 5
years
1 x lifetime
1x2
months
1x3
months
1x5
months
1x6
months
1 x year
2 x year
3 x year
Up to 4 x
year
1 x every 2
years
1 x every 3
years
1 x every 4
years
1 x every 5
years

List Any
Criteria for
ServiceCoverage
specific
Limitations
(eg. age
limits, toothspecific
limits,
or a cost or
dollar
threshold
above which
prior
authorization
is required)

List
Recommended
age
of visit?

Children’s
Dental
Service

*C.
Assessment
of risk for
tooth decay

Is the
Service
Covered
(Yes)

Is the Service
Covered
(Only with
Prior
Authorization

Is the
Service
Covered
(No)

Frequency
(Specify
periodicity)
Please
select from
the
following:

1 x lifetime
1x2
months
1x3
months
1x5
months
1x6
months
1 x year
2 x year
3 x year
Up to 4 x
year
1 x every 2
years
1 x every 3
years
1 x every 4
years
1 x every 5
years
1 x lifetime

*D. X-Rays

*i. Bitewing

1x2
months
1x3
months
1x5
months
1x6
months
1 x year

List Any
Criteria for
ServiceCoverage
specific
Limitations
(eg. age
limits, toothspecific
limits,
or a cost or
dollar
threshold
above which
prior
authorization
is required)

Children’s
Dental
Service

*ii. Full
Mouth

Is the
Service
Covered
(Yes)

Is the Service
Covered
(Only with
Prior
Authorization

Is the
Service
Covered
(No)

Frequency
(Specify
periodicity)
Please
select from
the
following:

2 x year
3 x year
Up to 4 x
year
1 x every 2
years
1 x every 3
years
1 x every 4
years
1 x every 5
years
1 x lifetime
1x2
months
1x3
months
1x5
months
1x6
months
1 x year
2 x year
3 x year
Up to 4 x
year
1 x every 2
years
1 x every 3
years
1 x every 4
years

List Any
Criteria for
ServiceCoverage
specific
Limitations
(eg. age
limits, toothspecific
limits,
or a cost or
dollar
threshold
above which
prior
authorization
is required)

Children’s
Dental
Service

*iii.
Panoramic

Is the
Service
Covered
(Yes)

Is the Service
Covered
(Only with
Prior
Authorization

Is the
Service
Covered
(No)

Frequency
(Specify
periodicity)
Please
select from
the
following:

1 x every 5
years
1 x lifetime
1x2
months
1x3
months
1x5
months
1x6
months
1 x year
2 x year
3 x year
Up to 4 x
year
1 x every 2
years
1 x every 3
years
1 x every 4
years
1 x every 5
years
1 x lifetime

List Any
Criteria for
ServiceCoverage
specific
Limitations
(eg. age
limits, toothspecific
limits,
or a cost or
dollar
threshold
above which
prior
authorization
is required)

*III. Treatment Services

Children’s
Dental Service

*A. Antimicrobial
treatments that
stop decay
from spreading
*B. Fillings
*i. Silver
amalgam
*ii. Tooth
colored
composite
*C.
Crowns/tooth
caps
*i. Stainless
steel crowns
*ii. Metal (only)
crowns
*iii.
Metal/porcelain
crowns
*iv. Porcelain
(only) crowns
*D. Root
Canals
(endodontics)
*i. Root canals
on baby teeth
(pulpotomies)
*ii. Root canals
on permanent
teeth

Is the
Service
Covered
(Yes)

Is the Service
Covered
(Only with
Prior
Authorization

Is the
Service
Covered
(No)

Frequency
(Specify
periodicity)
Please
select from
the
following:

List Any
Criteria for
ServiceCoverage
specific
Limitations
(eg. age
limits, toothspecific
limits,
or a cost or
dollar
threshold
above which
prior
authorization
is required)

Children’s
Dental Service

*E. Gum
(periodontal)
therapy
*F. Dentures
*i. Partial
dentures
*ii. Complete
dentures
*iii. Bridges
*G.
Orthodontics*
*i. Retainers
(orthodontic)
*ii. Braces
*H. Oral
surgery
*H. 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
*I. Treatment
of jaw joint

Is the
Service
Covered
(Yes)

Is the Service
Covered
(Only with
Prior
Authorization

Is the
Service
Covered
(No)

Frequency
(Specify
periodicity)
Please
select from
the
following:

List Any
Criteria for
ServiceCoverage
specific
Limitations
(eg. age
limits, toothspecific
limits,
or a cost or
dollar
threshold
above which
prior
authorization
is required)

Children’s
Dental Service

Is the
Service
Covered
(Yes)

Is the Service
Covered
(Only with
Prior
Authorization

Is the
Service
Covered
(No)

Frequency
(Specify
periodicity)
Please
select from
the
following:

List Any
Criteria for
ServiceCoverage
specific
Limitations
(eg. age
limits, toothspecific
limits,
or a cost or
dollar
threshold
above which
prior
authorization
is required)

problems
(TMJ)
*J. Emergency
room services
provided by a
dentist
*K. Inpatient
Hospital
Services
*L. Anesthesia
*i. General
anesthesia
*ii. Intravenous
conscious
sedation
*iii. Nonintravenous
conscious
sedation
*iv. Analgesia
(nitrous oxide)

* 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.

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improving this form, please write to CMS, 7500 Security Boulevard, Attn” PRA Reports Clearance Officer,
Mails Stop C4-26-05, Baltimore, Maryland 21244-1850.