Dental Services

(a)Emergency dental services (restoration, extraction and root canal treatment) which are necessary to alleviate severe pain and annual routine treatment (dental exams and cleaning) are covered for all persons age seventeen

(17)and above. MIP clients are responsible for twenty percent (20%) of the cost of each treatment.

(b)Dental Services Not Covered. The following shall not be covered as dental benefits under the provisions of the Medically Indigent Program:

(1)cosmetic or cosmetic related treatments;

(2)treatments initiated while not on existing plan;

(3)services or treatments not in accordance with accepted dental therapeutics;

(4)any services or procedure not listed in American Dental Association’s procedure codes;

(5)any treatment or service related to temporo-mandibular joint dysfunction syndrome (TMJ/TMD) or disease;

(6)posterior composites;

(7)broken appointment fees;

(8)dental implants and implant prosthesis; and

(9)orthodontics or orthodontic-related treatments.

(c)Limitations and Exclusions. All dental services are also subject to the stated Program benefit limitations and exclusions outlined in § 2912 through § 2913 as applicable.