Cal MediConnect Plan MEMBER GUIDEBOOK FOR YOUR DENTAL BENEFITS

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Cal MediConnect Plan

MEMBER GUIDEBOOK

FOR YOUR DENTAL BENEFITS

COUNTY: LOS ANGELES

Welcome to the Care1st Cal MediConnect Plan (Medicare-Medicaid Plan) dental program provided by Access Dental Plan/Premier Access! As a member of Care1st Cal MediConnect Plan, you have additional

supplemental dental benefits.

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Dear Member:

Welcome to Care1st Cal MediConnect Plan dental program provided by Access Dental Plan/Premier Access! As a Care1st Cal MediConnect Plan member, you can receive additional dental benefits, known as

supplements. Care1st and Access Dental Plan/Premier Access are teaming up to provide you with timely and appropriate access to dental services are no additional cost to you.

This Member Guidebook has information on your dental benefit plan. To view this guidebook on Care1st’s website, please go to: www.care1st.com/ca/calmediconnect. Please note that these documents are not

proof of coverage.

In Los Angeles County, you can access the dental services through Access Dental Plan network or through the Denti-Cal network. Please see options below and follow the instructions as applicable to you.

I am enrolled in (a member of) Access Dental Plan.

Please visit your assigned dentist in order to access services. You must bring your Care1st Cal

MediConnect Plan ID Card with you, so the dentist office can check your eligibility. If you have questions about your registered Access Dental provider/dental office, or would like to change your provider, please contact Access Dental Plan using the customer services information at the bottom of this page.

To see a complete listing of Access Dental network dentists, please refer to the Care1st Cal MediConnect Plan Provider Directory. This directory can be found on Care1st Cal MediConnect Plan website at

www.care1st.com/ca/calmediconnect > go to tab “Members” > click on “Member Materials.” For

assistance, you can contact Care1st Cal MediConnect Plan Member Services at 1-855-905-3825 (TTY: 711), 8:00 a.m. – 8:00p.m., seven days a week.

I am not enrolled in Access Dental Plan and would like to join.

If you join Access Dental Plan to access services through their network of dentist providers you will need to contact Medi-Cal Managed Care Health Care Options at 1-800-430-4263, between 8:00 a.m. to 5:00 p.m., Monday-Friday. TTY/TDD users should call 1-800-430-7077.

I am not enrolled in Access Dental Plan. What other options are available to receive dental services?

Visit any of the Denti-Cal network providers in order to access services. To find a dentist, please call Denti-Cal at 1-800-322-6384. You may also view a complete listing of available dentists on the Denti-Cal website at www.denti-cal.ca.gov. On the website, click the tab “Beneficiaries” on top of the page, and

click the first link “Help in locating a Medi-Cal dentist.” Then search for a provider, selecting Benefit Plan “Denti-Cal Medi-Cal Dental Program”.

If you have any questions or concerns, please email us at CustomerService@premierlife.com or call us at 1­

855-360-4243, Monday through Friday between the hours of 8:00 a.m. and 6:00 p.m. PST. For the hearing and speech impaired, call our TDD line at 1-877-688-9891. The email connect can also be found on our website under “Contact Us.”

Access Dental Plan/Premier Access plan is dedicated to provide Care1st Cal MediConnect Plan members with the benefits needed to attain and maintain good oral health. We encourage you to see your dentist on a regular basis. We look forward to help you reach your oral health care goals.

Sincerely,

ACCESS DENTAL PLAN/PREMIER ACCESS PLAN 1-855-360-4243 (TDD: 1-877-688-9891)

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You can get this information for free in other languages. Call 1-855-360-4243. TTY users should

call 1-877-688-9891. The call is free.

Puede recibir esta información sin cargo en otros idiomas. Llame al 1-855-360-4243. Los

usuarios de TTY deben llamar al 1-877-688-9891. La llamada es gratuita.

您可免费获得本资讯的其他语言版本。请致电免费电话 1-855-360-4243,听障及语障人士请致电

1-877-688-9891。

您可免費獲得本資訊的其他語言版本。請致電免費電話 1-855-360-4243。聽障及語障人士請致電

1-877-688-9891。

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Эту информацию вы можете получить бесплатно в переводе на другие языки. Позвоните

по телефону 1-855-360-4243. Пользователи TTY должны позвонить 1-877-688-9891.

Звонки по этому телефону бесплатные.

Maaari ninyong makuha nang libre ang impormasyon na ito sa ibang mga wika. Tawagan ang 1­

855-360-4243. Ang gumagamit ng TTY ay dapat tumawag sa 1-877-688-9891. Libre ang tawag.

Quý vị có thể nhận thông tin này miễn phí bằng các ngôn ngữ khác. Hãy gọi 1-855-360-4243.

Người sử dụng TTY nên gọi 1-877-688-9891. Cuộc gọi này được miễn phí.

Care1st Health Plan is a health plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees. This is not a complete list. The benefit information is a brief summary, not a complete description of benefits. For more information contact the plan or read the Member Handbook. Limitations, copays, and restrictions may apply. For more information, call Care1st Cal MediConnect Plan Member Services or read the Care1st Cal MediConnect Plan Member Handbook. Benefits, List of Covered Drugs, pharmacy and provider networks, and/or copayments may change on January 1 of each year.

Call Care1st Cal MediConnect Plan Member Services at 1-855-905-3825 (TTY: 711), 8:00 a.m. – 8:00p.m., seven days a week. The call is free.

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Table of Contents

Member Frequently Asked Questions (FAQs)……….Page 4

Schedule of Benefits……… ...………..Page 5-9

List of Covered Services……… ...…………..Page 5-8

Limitations and Exceptions ………..Page 9

Contact Information………Page 10

Access Dental Plan/Premier Access Plan Customer Service: 1-855-360-4243 For the Hearing impaired (TDD: 1-877-388-9891)

Website: www.premierlife.com/calmediconnect

Care1st Cal MediConnect Plan Member Services: 1-855-905-3825 For the Hearing impaired (TTY: 711)

Website: www.care1st.com/ca/calmediconnect

8:00 a.m. – 6:00 p.m., Monday through Friday

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MEMBER Frequently Asked Questions (FAQs)

o What dental benefits are available?

As part of Care1st Cal MediConnect Plan, you are able to receive additional dental services, which are not covered through Medi-Cal Dental. For the listing of benefits available, please see your Schedule of Benefits starting on the next page of this guidebook. You can also find this guidebook located online at:

www.premierlife.com/calmediconnect.

o What are some examples of covered* services?

o Crowns o Root Canals o Partial Dentures o Bridges

*You should discuss all treatment options with your Dentist prior to services being rendered.

o Where can I go to receive these dental benefits?

o If you are enrolled in (a member of) Access Dental Plan, you need to visit your assigned dentist. If you are not yet enrolled and would like to join, please contact Medi-Cal Managed Care Health Care Options at 1-800-430-426,3 between 8:00 a.m. to 5:00 p.m., Monday-Friday. TTY/TDD users should call 1-800­ 430-7077.

o If you are not enrolled in Access Dental Plan, you may visit any of the Denti-Cal network providers.

For information on how to view the complete listing of Access Dental network dentist and/or the dentists available through Denti-Cal, please refer to instructions on page 2 of this guidebook.

o Do I have to pay for these services?

Most services are provided for you, at no cost. If you choose to upgrade the material, then you will be required to pay for the additional lab costs. Please see your Schedule of Benefits starting on the next page. All asterisk (*) benefits are those that are considered an upgrade.

Before agreeing to any charges and billing, you should contact Access Dental Plan/Premier Access Plan customer service at 1-855-360-4243 (TDD: 1-877-388-9891), 8:00 a.m. – 6:00 p.m., Monday through Friday.

o What do I need to show my dentist to know that I am eligible?

o If you are enrolled in (a member of) Access Dental Plan, show your Access Dental Plan ID card or ask your provider to either go online (www.premierlife.com) or they can call1-855-360-4243 to verify eligibility.

o If you are not enrolled in Access Dental Plan, show your dentist your Care1st Cal MediConnect Plan ID Card and let them know you are a member of Premier Access Dental. Your ID Card will not indicate Premier Access Plan however they can call 1-855-360-4243 if they have questions about your eligibility.

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Schedule of Benefits

Care1st Cal MediConnect Plan dental program provided by Access Dental Plan/Premier Access Plan

Starting on the next page is the list of services available to you under your Care1st Cal MediConnect Plan. Most services are provided at zero cost to you as the member. Please keep in mind that there are

guidelines on page 8 that indicate the situations when you would be responsible for a payment.  Most covered dental services require a prior authorization in order for your provider to perform the

services. All procedure processing guidelines will follow the Denti-Cal guidelines listed in the Provider Handbook.

 Eligibility is determined by Care1st and your enrollment into the Cal MediConnect Program. For all questions regarding enrollment and eligibility please contact Care1st Cal MediConnect Plan Member Services at (855) 905-3825 (TTY: 711).

 All covered dental services must be determined to be medically necessary benefits, consistent with professionally recognized standards of dental practice.

 Dental services covered under the Cal MediConnect Program are optional services that are included as additional benefits by the health plan. Since these Care Plan Option (CPO) services are not part of covered Medi-Cal benefits today, these services are not subject to Medi-Cal (or other applicable) grievance and appeals processes.

 You will not receive a separate dental ID Card to utilize these services. Your Care1st Cal MediConnect Plan ID Card will be used to help check your eligibility.

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CDT Code Description Coinsurance Diagnostic

D0140 Limited oral evaluation $0

D0180 Comprehensive periodontal evaluation $0

D0240 Intraoral, occlusal film $0

D0273 Bitewings, 3 films $0

Preventive

D1310 Nutritional counseling for control of dental disease $0 D1320 Tobacco counseling, control/prevention oral disease $0

D1330 Oral hygiene instruction $0

Restorative

D2720 Crown, resin with high noble metal $0*

D2721 Crown, resin with predominately base metal $0

D2722 Crown, resin with noble metal $0*

D2750 Crown, porcelain fused to high noble metal $0*

D2751 Crown, porcelain fused to predominantly base metal $0

D2752 Crown, porcelain fused to noble metal $0*

D2790 Crown, full cast high noble metal $0*

D2791 Crown, full cast predominantly base metal $0

D2792 Crown, full cast noble metal $0*

D2933 prefabricated stainless steel crown with resin window $0

D2950 Core buildup, including any pins $0

D2951 Pin retention, per tooth, in addition to restoration $0 D2953 Each additional indirect fabricated post, same tooth $0*

Endodontic

D3110 Pulp cap, direct (excluding final restoration) $0

D3120 Pulp cap, indirect (excluding final restoration) $0

D3320 Bicuspid (excluding final restoration) $0

D3330 Molar (excluding final restoration) $0

D3331 Treatment of root canal obstruction; non-surgical $0

D3332 Incomplete endodontic therapy, unrestorable $0

D3347 Retreatment of previous root canal, bicuspid $0

D3348 Retreatment of previous root canal, molar $0

D3410 Apicoectomy/periradicular surgery; anterior $0

D3421 Apicoectomy/periradicular surgery, bicuspid $0

D3425 Apicoectomy/periradicular surgery, molar $0

D3426 Apicoectomy/periradicular surgery, ea. add. root $0

Periodontic

D4341 Periodontal scaling & root planing, 4+ teeth/quad. $0 D4342 Periodontal scaling & root planing, 1-3 teeth/quad. $0 D4355 Full mouth debridement (removes buildup around teeth, below gums) $0 D4381 Localized delivery of antimicrobial agent/per tooth $0

D4910 Periodontal maintenance $0

D4999 Unspecified periodontal procedure, by report $0

Removable Prosthodontics (Dentures)

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D5211 Maxillary (upper) partial denture, resin based $0

D5212 Mandibular (lower) partial denture, resin based $0

D5213 Maxillary (upper) partial denture, cast metal framework/resin based $0 D5214 Mandibular (lower) partial denture, cast metal framework/resin based $0

D5421 Adjust partial denture, maxillary (upper) $0

D5422 Adjust partial denture, mandibular (lower) $0

D5640 Replace broken teeth, per tooth $0

D5650 Add tooth to existing partial denture $0

D5660 Add clasp to existing partial denture $0

D5740 Reline maxillary (upper) partial denture, chairside $0

D5741 Reline mandibular partial denture, checklist $0

Fixed Prosthodontics (Bridges)

D6240 Pontic, porcelain fused to high noble metal $0**

D6241 Pontic, porcelain fused to predominately base metal $0*

D6242 Pontic, porcelain fused to noble metal $0**

D6750 Crown, porcelain fused to high noble metal $0**

D6751 Crown, porcelain fused to predominantly base metal $0*

D6752 Crown, porcelain fused to noble metal $0**

Extractions & Oral Surgery

D7310 Alveoloplasty (smoothing the jaw ridge) with extractions, 4+ teeth, quadrant $0 D7311 Alveoloplasty with extractions, 1-3 teeth, quadrant $0 D7320 Alveoloplasty without extractions, 4+ teeth, quadrant $0 D7321 Alveoloplasty without extractions, 1-3 teeth, quadrant $0

D7910 suture of recent small wounds up to 5cm $0

Adjunctive General Services

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*Guidelines:

If the covered benefit is upgraded to include noble or high noble metal, the provider may charge the member the additional lab cost of the upgraded metal.

Porcelain/resin fused to metal crowns on molar teeth is considered an upgrade. If a porcelain/resin fused to metal crown on a molar tooth is

provided, the provider may charge the member the additional lab cost of the porcelain/resin.

Porcelain/resin fused to base metal crowns are covered benefits for anterior and bicuspid teeth.

Cast base metal restorations are covered benefits for molar teeth.

No more than two (2) quadrants of periodontal scaling and root planing per appointment/per day are allowable.

** Guidelines for Pontics and Abutment Crowns Fixed bridges are only covered as described:

An anterior fixed bridge (porcelain fused to predominantly base metal) is covered subsequent to the recent extraction of up to two anterior teeth when:

> Those extracted teeth are the only missing teeth in the arch (other than 3rd molars), and;

> The attachment teeth immediately adjacent to the extraction site(s) have a good prognosis.

Appropriate procedure codes for an anterior fixed bridge are:

> D6751: an attachment crown for one tooth next to the extraction space > D6241: the replacement tooth (pontic)

> D6751: an attachment crown for the tooth on the other side of the extraction space.

If the covered anterior fixed bridge is updated to include noble or high noble metal, the provider may charge the member the additional lab cost of the upgraded metal.

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Limitations:

1. Oral examinations are covered once every six (6) consecutive months.

2. Periodontal maintenance is covered once every six (6) consecutive months.

3. Crowns and pontics are benefits on the same tooth only once every five (5) years, and consistent with professionally recognized standards of dental practice.

4. Replacement of full and partial denture are covered once per arch every five (5) years, except when they cannot be made functional through reline or repair.

5. Denture relines are covered two (2) times per year, and only when consistent with professionally recognized standards of dental practice.

Exclusions:

1. Any procedure not specifically listed as a covered benefit.

2. Replacement of lost or stolen prosthetics or appliances including crowns, bridges, partial dentures and full dentures.

3. Any treatment requested, or appliance made, which are either not necessary for maintaining or improving dental health, or are for cosmetic purposes unless otherwise covered as a benefit. 4. Orthodontic treatment.

5. Procedures considered experimental, treatment involving implants or pharmacological regimens. 6. Oral surgery requiring the setting of bone fractures or bone dislocations.

7. Hospitalization.

8. General anesthesia, analgesia,

intravenous/intramuscular sedation or the services of an anesthesiologist.

9. Treatment started before the member was eligible, or after the member was no longer eligible. 10. Procedures which are determined not to be dentally necessary consistent with professionally recognized standards of dental practice.

11. Appliances needed to increase vertical dimensions or restore occlusion.

12. Procedures, appliances, or restorations to correct congenital, developmental or medically induced dental disorder, including but not limited to: myofunctional (e.g. speech therapy), myoskeletal, or temporomandibular joint dysfunctions (e.g. adjustments/corrections to the facial bone. 13. Treatment of malignancies, cysts, or neoplasms.

14. Any services performed outside of the assigned dental office, unless expressly authorized by

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Contact Information

Access Dental Plan/Premier Access Plan Customer Service: 1-855-360-4243 For the Hearing impaired (TDD: 1-877-388-9891)

8:00 a.m. – 6:00 p.m., Monday through Friday Website: www.premierlife.com/calmediconnect

Email: CustomerService@premierlife.com

Care1st Cal MediConnect Plan Member Services: 1-855-905-3825 For the Hearing impaired (TTY: 711)

8:00 a.m. – 8:00 p.m., seven days a week Website: www.care1st.com/ca/calmediconnect

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