Most dental services are not covered. For example, dental implants, orthodontic services, and treatment for damage to teeth or gums caused by biting, chewing, grinding, or any combination of these is not covered. However, your PEBB dental plan may cover these services. Note: UMP Classic and UMP CDHP are not affiliated with the Uniform Dental Plan (UDP). If you are enrolled in UDP, please contact UDP for information.
For dental services that are covered by the plan, you pay 20% of the allowed amount. Only the following dental services are covered:
General Anesthesia During a Dental Procedure
General anesthesia performed during a dental procedure is covered only when:
- It is provided by an anesthesiologist in a hospital or ambulatory surgery center.
- The charges for the hospital or ambulatory surgery center are covered by the plan (see "Dental Procedures Performed in a Hospital or Ambulatory Surgery Center" below).
Dental Procedures Performed in a Hospital or Ambulatory Surgery Center
Dental procedures performed in a hospital or ambulatory surgery center are covered only when the enrollee:
- Is under age 7 with a dental condition that cannot be safely and effectively treated in a dental office; or
- Has a dental condition that cannot be safely and effectively treated in a dental office because of a physical or developmental disability; or
- Has a medical condition that would put the enrollee at undue risk if the procedure were performed in a dental office.
To receive coverage for repair of an accidental injury to natural teeth, the injury must be evaluated and a treatment plan developed and finalized within 30 days of the injury.
The actual treatment may extend beyond 30 days if your provider determines treatment should start later or continue longer. Treatment must be completed by the end of the calendar year following the accident, and you must be currently enrolled in UMP during the entire course of treatment. The plan does not cover treatment after UMP coverage ends.
You have an accident on March 12, 2015, resulting in injuries that are covered by the plan. Your treatment plan must be finalized no later than April 11, 2015. All related treatment must be completed no later than December 31, 2016 (the calendar year following the accident).
The plan does not cover treatment that:
- Was not included in the treatment plan developed within the first 30 days following the accident.
- Extends past the end of the calendar year following the accident.
Only the following oral surgery procedures are covered, whether performed by a dentist or a medical professional:
- Excision of tumors or cysts of the jaw, cheeks, lips, tongue, gums, roof and floor of the mouth, or restorative surgery required by the excision.
- Incision of salivary glands or ducts.
- Obturator maintenance for cleft palate.
- Gum reduction for gingival hyperplasia due to Dilantin or phenytoin use.
- Jaw reconstruction and services related to cancer and treatment of cancer.
- Treatment of a fracture or dislocation of the jaw or facial bones.
- Treatment related to chronic conditions that result in loss or damage of teeth.