Florida Healthy Kids | Low Cost Insurance for Kids

?Dental Benefits OverviewIn accordance with section 409.815(2)(q), Florida Statutes, dental benefits provided by the Florida Healthy Kids Corporation (“FHKC”) are those dental benefits provided to children by the Florida Medicaid program under section 409.906(6), Florida Statutes, and as required by federal law. Incorporation by Reference The following rules are hereby incorporated by reference to the extent they govern benefit coverage, limitations, and exclusions related to the Benefits Schedule:Rule 59G-4.002, F.A.C., Dental General Fee Schedule; Practitioner Fee Schedule; Prescribed Drugs (not reviewed by the pharmaceutical and therapeutics committee) Fee Schedule; Prescribed Drug Fee Schedule; Federally Qualified Health Center Billing Codes; and County Health Department Billing. Rule 59G-4.055, F.A.C.Rule 59G-4.060, F.A.C.Rule 59G-4.100, F.A.C. Rule 59G-4.207, F.A.C.Rule 59G-4.250, F.A.C.However, the incorporation of these rules does not include coverage for Early and Periodic Screening, Diagnosis, and Treatment services and does not expand the scope of coverage beyond the dental benefits provided to children under section 409.906(6), Florida Statutes, and as required by federal law.Cost Sharing Enrollees are not subject to any cost-sharing. Covered ServicesAdjunctive General ServicesCovered services include:Behavioral management; up to three times per 366-day period.Intravenous/Non-intravenous Sedation; up to three times per 366-day period. Palliative TreatmentDiagnostic ServicesCovered services include:Oral evaluations One comprehensive evaluation every three yearsLimited evaluations, as medically indicatedOne periodic evaluation every 181 daysOne assessment (D0191) every 181 daysOne screening (D0190) every 181 daysDiagnostic imagingBitewing radiograph(s) every 181 daysOne complete series of intraoral radiographs every three yearsOne panoramic radiograph every three yearsThe following are not covered: Dental screenings or assessments performed by a registered dental hygienist on the same date of service as an evaluation performed by a dentist. Individual periapical radiograph(s) on the same date of service when the reimbursement amount exceeds that of a complete series. Intraoral-complete series and panoramic film on the same date of service. Endodontic ServicesCovered services include services to treat the dental pulp and surrounding tissues. Orthodontic ServicesCovered services include orthodontic services for enrollees with handicapping malocclusions, limited to:Up to 24 units within a 36-month period, including the removal of appliances and retainers at the end of treatmentOne replacement retainer(s) per arch, per lifetimePeriodontal ServicesCovered services include services to diagnose and treat the diseases of the supporting and surrounding tissues of the teeth. Full mouth scaling performed on the same date of service as root planing or periodontal scaling is not covered. Preventive ServicesCovered services include:One oral prophylaxis once every 181 daysTopical fluoride applicationVarnish:Once every 90 days for enrollees under age sixOnce every 181 days for enrollees age six and olderNon-varnish fluoride applications once every 181 daysSilver diamine fluoride once every 181 days per toothSealants, limited to one application per tooth (permanent molar) every three yearsProsthodontic ServicesCovered services include those services to diagnose, plan, rehabilitate, fabricate, and maintain dentures as follows:One of the following per enrolleeOne upper setOne lower setOne complete set of full denturesRemovable partial denturesOne reline, per denture, per 366-day periodOne all-acrylic interim partial (flipper) for the anterior teethRestorative ServicesCovered services include all-inclusive restorative services as follows:RestorationsAnesthesia is covered for restorative services only when not billed separatelyCrowns Surgical Procedures and ExtractionsCovered services include:Surgical procedures and extraction servicesEmergency dental services to alleviate pain and/or infectionProcedures essential to prepare the mouth for denturesSurgical and adjunctive treatment of diseases, injuries, deformities, and defects of the oral and maxillofacial areasExclusionsThe following services are excluded from coverage:Services that do not meet the requirements of Medical NecessityServices that unnecessarily duplicate another provider’s serviceExperimental or investigational drug, biological product, device, medical treatment, or procedure that meets any of the following criteria, as determined by Insurer: Reliable evidence shows the drug, biological product, device, medical treatment, or procedure when applied to the Enrollee’s circumstances is the subject of ongoing phase I, II, or III clinical trials; Reliable evidence shows the drug, biological product, device, medical treatment, or procedure when applied to the Enrollee’s circumstances is under study with a written protocol to determine maximum tolerated dose, toxicity, safety, or efficacy in comparison to conventional alternatives; orReliable evidence shows the drug, biological product, device, medical treatment, or procedure when applied to the Enrollee’s circumstances is being delivered or should be delivered subject to the approval and supervision of an Institutional Review Board as required and defined by federal regulations, particularly those of the U.S. Food and Drug Administration or the Department of Health and Human Services. Prescription drugs and services provided in a hospital, urgent care center, or emergency department (these are benefits covered by the Enrollee’s Florida Healthy Kids health plan). Early and Periodic Screening, Diagnosis, and Treatment services. ................
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