What MIChild Covers

• Clinical Oral Examinations, including:
• Initial oral examination,
• Periodic oral examination,
• Emergency oral exam, and
• Pedodontic specialty exam (licensed pedodontist only)

Limitation: Up to two examinations of any type per Member will be paid for in a period of 12 consecutive months.

• Bitewing X-rays

Limitation: The radiographic services covered are bitewing X-rays. They will be paid for up to once per Member in a period of 12 consecutive months.

• Dental Prophylaxis (Teeth cleaning)

Limitation: Dental prophylaxes will be paid for up to twice per Member in a period of 12 consecutive months.

• Fluoride Treatment (Topical fluoride treatment excluding prophylaxis)

Limitation:Fluoride treatments will be paid for up to twice in a period of 12 consecutive months. Benefits for fluoride treatments will only be paid for up to the child's 14th birthday.

• Sealants

Limitation: Sealants can only be paid for when they are done on the occlusal (biting) surface of first permanent molars for patients up to age nine and second permanent molars for patients up to age 14. The occlusal surface of these teeth must not have cavities and fillings. Sealants will be paid for up to once per tooth per Member's lifetime.

• Fixed and removable space maintainers
• Recementation of space maintainer

Limitation: Space maintenance services are limited to the applying and maintaining of space maintainers. Only one space maintainer is provided for a space.

• Amalgam Restorations (silver fillings)
• Resin Restorations (anterior teeth only)

Limitation:Resin (tooth colored) restorations on posterior (back) teeth are not covered. If the MIChild Member has this kind of resin restoration, the amount that would have been paid for an amalgam restoration will be paid to help with the cost. The additional cost will be the responsibility of the MIChild Member.

• Re-cement Crown
• Sedative Filling
• Pins - per tooth (in addition to restorations)

• Prefabricated stainless steel crown

• Therapeutic Pulpotomy

Limitation: This service is covered only on primary (baby) teeth.

• Simple Extractions (includes local anesthesia and routine post-operative care)

• Emergency Palliative Treatment

The maximum dollar amount that Delta Dental will pay per Member per contract year for covered dental services is $600. The contract year begins on January 1 and ends on December 31 of each year. If, during the contract year, the Member receives covered dental services that cost more than $600, the member is responsible for paying all charges above $600.

The following services are NOT benefits. You will be responsible for the charges for these services:

• Fluoride treatment and the application of space maintainers for children age 14 and older
• Prosthodontic services (for example, bridges, partial dentures, complete dentures)
• Orthodontic services (for example, braces)
• Periodontal services (treatment for gum disease)
• Endodontic services except as specified (for example, root canals)
• Oral surgery procedures except as specified. Surgical extractions are not a covered dental benefit. Surgical extractions may be covered under your medical insurance.
• Major restorative services (for example, single crowns other than stainless steel, inlays, onlays)
• X-rays except for bitewing X-rays

No payments are provided for the following services. You will be responsible for the charges for these services:

(1) Services for injuries or conditions payable under Workers' Compensation or Employer's Liability laws; or benefits or services that are available from any federal or state government agency, from any municipality, county or other political subdivision or community agency, or from any foundation or similar entity.
NOTE: This provision does not apply to any programs provided under Title XIX Social Security Act; that is, Medicaid.

(2) Services or appliances started before an individual became eligible under this plan.

(3) Prescription drugs, laboratory tests and/or examinations, premedications and/or relative analgesia; charges for hospitalization; general anesthesia and/or intravenous sedation; preventive control programs, including home care items; and charges for failure to keep a scheduled visit with the dentist.

(4) Lost, missing or stolen appliances of any type.

(5) Services that are not necessary and/or customary as determined by the standards of generally accepted dental practice.

(6) Services for which no valid dental need can be demonstrated or that are specialized techniques.

(7) Appliances, surgical procedures and restorations for increasing vertical dimension; for restoring occlusion; for replacing tooth structure loss resulting from attrition, abrasion or erosion; for correcting congenital or developmental malformations; for aesthetic purposes; or for implantology techniques.

(8) Treatment by someone other than a dentist, except for the cleaning of teeth and topical application of fluoride, which can be done by a licensed dental hygienist under the supervision and guidance of a dentist.

(9) Those services and benefits excluded by the rules and regulations of Delta Dental, including the processing policies, which may change periodically.

(10) Services or supplies for which no charge is made, for which the patient is not legally obligated to pay or for which no charge would be made in the absence of Delta Dental coverage.

(11) Services or supplies received as a result of dental disease, defect or injury due to an act of war, declared or undeclared.

(12) Services that are covered under a hospital, surgical/medical or prescription drug program.

(13) Appliances, restorations or services for the diagnosis or treatment of disturbances of the temporomandibular joint (TMJ).

The benefits provided by Delta Dental for the following services are limited as follows. All time limitations are measured from the date when those services were last covered by a Delta Dental plan.

(1) Optional treatment: If you select a more expensive service than is customarily provided, or for which Delta Dental does not believe a valid dental need is shown, Delta Dental will pay only its part of the fee for the service, if any, that is customarily provided.
    For example, if a posterior (back) tooth can be satisfactorily restored with a silver filling and you decide to have the tooth restored with a more costly material (such as a resin or tooth-colored material), the plan will pay only the amount that it would have paid to restore the tooth with the silver filling. You are responsible for the difference in cost.

(2) Delta Dental's obligation for payment of benefits ends on the last day of the month in which an individual becomes ineligible for benefits.

(3) When services in progress are interrupted and completed later by another dentist, Delta Dental will review the claims to determine the amount of payment, if any, to each dentist.