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

Summary of Benefits Form
CMS-10291
Program Type: MEDICAID
State:
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.
Children’s Dental
Service

I. Preventive
Services
A. Cleanings

Is the Service
Covered (Yes)

Is the Service
Covered (Only
with Prior
Authorization)

Is the Service
Covered (No)

Frequency
(Specify
Periodicity)
Please choose
from the
following:

1 x 2 months
1 x 3 months
1 x 5 months
1 x 6 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 ServiceSpecific
Limitations (e.g.,
age limits, toothspecific limits, or
a cost or dollar
threshold over
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 choose
from the
following:

1 x every 5 years
1 x lifetime
. Fluoride
treatments
(including fluoride
varnishes)

C. Sealants (list
any tooth-specific
limits)

1 x 2 months
1 x 3 months
1 x 5 months
1 x 6 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
1 x 2 months
1 x 3 months
1 x 5 months
1 x 6 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 ServiceSpecific
Limitations (e.g.,
age limits, toothspecific limits, or
a cost or dollar
threshold over
which prior
authorization is
required)

Criteria for
Coverage

Children’s Dental
Service

D. Space
maintainers

II. Diagnostic
Services
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 choose
from the
following:

1 x 2 months
1 x 3 months
1 x 5 months
1 x 6 months
1 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
1 x 2 months
1 x 3 months
1 x 5 months
1 x 6 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 ServiceSpecific
Limitations (e.g.,
age limits, toothspecific limits, or
a cost or dollar
threshold over
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 choose
from the
following:

1 x lifetime

B. Dental
examinations

C. Assessment of
risk for tooth
decay

1 x 2 months
1 x 3 months
1 x 5 months
1 x 6 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
1 x 2 months
1 x 3 months
1 x 5 months
1 x 6 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 ServiceSpecific
Limitations (e.g.,
age limits, toothspecific limits, or
a cost or dollar
threshold over
which prior
authorization is
required)

List
Recommended
age of visit?

Criteria for
Coverage

Children’s Dental
Service

D. X-Rays
i. Bitewing

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 choose
from the
following:

1 x 2 months
1 x 3 months
1 x 5 months
1 x 6 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
1 x 2 months
1 x 3 months
1 x 5 months
1 x 6 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 ServiceSpecific
Limitations (e.g.,
age limits, toothspecific limits, or
a cost or dollar
threshold over
which prior
authorization is
required)

Criteria for
Coverage

Children’s Dental
Service

iii. Panoramic

III. Treatment
Services
A. Anti-microbial
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

Is the Service
Covered (Yes)

Is the Service
Covered (Only
with Prior
Authorization)

Is the Service
Covered (No)

Frequency
(Specify
Periodicity)
Please choose
from the
following:

1 x 2 months
1 x 3 months
1 x 5 months
1 x 6 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 ServiceSpecific
Limitations (e.g.,
age limits, toothspecific limits, or
a cost or dollar
threshold over
which prior
authorization is
required)

Criteria for
Coverage

Children’s Dental
Service

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
E. Gum
(periodontal)
therapy
F. Dentures
i. Partial dentures
ii. Complete
dentures
iii. Bridges
G. Orthodontics*
i. Retainers
(orthodontic)
ii. Braces
H. Oral surgery
i. Simple
extractions
ii. Surgical
extractions

Is the Service
Covered (Yes)

Is the Service
Covered (Only
with Prior
Authorization)

Is the Service
Covered (No)

Frequency
(Specify
Periodicity)
Please choose
from the
following:

List Any ServiceSpecific
Limitations (e.g.,
age limits, toothspecific limits, or
a cost or dollar
threshold over
which prior
authorization is
required)

Criteria for
Coverage

Children’s Dental
Service

iii. Care of
abscesses
iv. Cleft palate
treatment
v. Cancer
treatment
vi. Treatment of
fractures
vii. Biopsies
I. Treatment of
jaw joint
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

Is the Service
Covered (Yes)

Is the Service
Covered (Only
with Prior
Authorization)

Is the Service
Covered (No)

Frequency
(Specify
Periodicity)
Please choose
from the
following:

List Any ServiceSpecific
Limitations (e.g.,
age limits, toothspecific limits, or
a cost or dollar
threshold over
which prior
authorization is
required)

Criteria for
Coverage

Children’s Dental
Service

Is the Service
Covered (Yes)

iv. Analgesia
(nitrous oxide)

Is the Service
Covered (Only
with Prior
Authorization)

Is the Service
Covered (No)

Frequency
(Specify
Periodicity)
Please choose
from the
following:

List Any ServiceSpecific
Limitations (e.g.,
age limits, toothspecific limits, or
a cost or dollar
threshold over
which prior
authorization is
required)

Criteria for
Coverage

* 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.

PRA Disclosure Statement:
The Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA) sections 501(f)(1) and (2), require that state-specific
information on Medicaid and CHIP dental providers and benefits be posted on the Insure Kids Now (IKN) website, and that States
update the information on the dental providers quarterly and the information on their benefit package annually thereafter. Under
the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law.
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 (Expires:
6/30/2021). The time required to complete this information collection of dental benefits information is estimated to average 25
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, Mail Stop C4-26-05,
Baltimore, Maryland 21244-1850.