In Home Supportive Services - My Benefit Choices

In Home Supportive Services
San Mateo County
San Mateo County
Public Authority
San Mateo County IHSS Workers’
Dental and Vision Insurance
Enrollment Information
®

San Mateo County
Public Authority
Estimado Trabajador del Cuidado Personal:
La Autoridad Pública del Condado de San Mateo del Servicio de Asistencia en el Hogar se complace en
ofrecer cobertura dental y de visión para nuestros proveedores a través de Anthem Blue Cross Dental y
AIG / Servicios Médicos de los ojos (MES).
La elegibilidad inicial para los beneficios dentales y de visión requiere que los proveedores trabajen 35
horas o más por mes durante dos meses consecutivos. Una vez inscrito en los planes el un proveedor
deberá de seguir trabajando 35 horas cada mes. El reporte de horas trabajadas debe de ser entregado
inmediatamente después del último día del período de pago para asegurarse de que las horas trabajadas
se registren.
Si usted es elegible para la cobertura dental y de la vista, le informamos que la cobertura para dependientes
está también disponible como una opción, tanto para el plan dental como para el de la vista. Si usted
decide inscribir a su(s) dependiente(s) el costo del seguro será su responsabilidad. La información sobre
la cobertura de dependientes será enviada a usted por el Centro de Servicio de Beneficios (Benefit Service
Center) una vez que usted sea elegible para dicha cobertura.
Obtenga más información sobre los planes dentales y de la vista ofrecidos, revisando el material
proporcionado en este folleto.
Para mayor información acerca de los planes dentales y de la vista, favor de llamar al Centro de Servicio
de Beneficios (Benefit Service Center ) al 800-842-6635, de Lunes a Viernes de 8:30 am a 5:00 pm.
También puede visitar la pagina web www.mybenefitchoices.com/ihss.
Sinceramente,
La Autoridad Pública del Condado de San Mateo
(San Mateo County Public Authority)
San Mateo County IHSS Workers’ Insurance Enrollment Information • [ ] 2

San Mateo County
Public Authority
Dear Homecare Worker:
The San Mateo County Public Authority for In-Home Supportive Services is pleased to offer dental and
vision coverage for our providers through Anthem Blue Cross Dental and AIG/Medical Eye Services
(MES).
Initial eligibility for the dental and vision benefits requires providers to work 35 hours or more per month
for two consecutive months. Once enrolled in the plans, a provider must continue to work 35 hours each
month. Timesheets must be turned in immediately following the last day of the pay period to ensure that
hours worked are recorded.
If you are eligible for dental and vision coverage, dependent coverage is also available as an option on
both the dental and vision plans. If you choose to enroll your dependents, you will be responsible for the
cost of the insurance. Information about dependent coverage will be mailed to you by the Benefit Service
Center once you become eligible for coverage.
Find out more about the dental and vision plans offered by reviewing the material provided in this
booklet.
For more information regarding your dental and vision plans, please call the Benefit Service
Center at 800-842-6635, Monday through Friday from 8:30 am to 5:00 pm. You can also visit
www.mybenefitchoices.com/ihss.
Sincerely,
San Mateo County Public Authority
San Mateo County IHSS Workers’ Insurance Enrollment Information • [ 3 ]

Eligibility Requirements
Who is eligible?
There are 2,200 dental and vision slots for San Mateo
County IHSS providers. The eligibility rules are as follows:
1. To apply for benefits you must work a minimum of 35
hours per month for two consecutive months. Once you are
added to the dental and vision program, you must continue
to work a minimum of 35 hours per month and submit your
timesheets immediately following the end of each pay period.
2. Dental and vision benefits are terminated if you haven’t
worked 35 hours or fail to report your hours on time for
two consecutive months. You will receive a warning
letter after one month of low hours and your coverage will
be terminated after two months of low hours or failure
to report your hours on time. If you regain eligibility,
you will need to contact the Public Authority Benefits
Office at (650) 573-3773 to request a new application.
3. If you are eligible and all 2,200 slots are filled, you will be
placed on the wait list based on the date of receipt of your
application.
Who pays for the coverage?
The cost of single dental coverage is $5.00 per month, which
will be deducted from your paycheck. You are provided with
single vision coverage at no cost to you. The cost for dental and
vision dependent coverage is your responsibility by way of direct
automatic bill payment to the Benefit Service Center. Contact the
Benefit Service Center for the monthly cost of dependent coverage.
You must be eligible for single coverage based on the eligibility
rules above to cover your dependents.
When does coverage begin and end?
Coverage will continue each month that you submit a timesheet
immediately after the end of the pay period that shows that you
worked a minimum of 35 hours. Coverage ends when your hours
worked drop below 35 hours for two consecutive months. This can
occur due to a loss of hours or by not submitting your timesheets
immediately following the end of the pay period.
San Mateo County IHSS Workers’ Insurance Enrollment Information • [ 4 ]

General Benefit Information
Benefit Service Center
Both your dental and vision insurance plans are coordinated and
administered by the Benefit Service Center, Inc., 9500 Topanga
Canyon Blvd, Chatsworth, CA 91311. For any questions regarding
your dental and vision benefits, please call:
The Benefit Service Center at 800-842-6635
Monday through Friday
8:30 a.m. to 5:00 p.m.
The Benefit Sevice Center can assist you with the following:
• Payments for dental and/or vision dependent coverage
• Request forms and cost information to add dependents
• Answers to general dental and/or vision benefit questions
• Request an Anthem Blue Cross Dental Evidence of
Coverage Booklet
• Request a replacement for lost dental or vision ID cards
• Update address and/or phone number
• Assistance resolving an unpaid dental or vision claim
You can also visit the Benefit Service Center IHSS website at:
www.mybenefitchoices.com/ihss. The website provides a single
point of reference for Dental and Vision benefit information,
including:
• IHSS dental and vision booklet
• Anthem Blue Cross Dental Evidence of Coverage booklet
• Dental and Vision benefit summaries
• How to find a dentist or vision doctor in your area
San Mateo County IHSS Workers’ Insurance Enrollment Information • [ 5 ]

Dental Insurance
Anthem Blue Cross provides your dental benefits which include
orthodontia. A summary of dental benefits is included in this
booklet.
To enroll your eligible dependent(s) on the dental plan, you
are required to complete a Group Membership Change Form
and an Authorization for Direct Automatic Bill Payment Form.
THE CHANGE FORM AND BILL PAYMENT FORM MUST
BE SUBMITTED WITHIN 90 DAYS OF YOUR INITIAL
ENROLLMENT DATE. Call the Benefit Service Center at 800-
842-6635 to request the change form. Send the completed forms
back to the Benefit Service Center by one of the following:
• Fax to 818-678-0030
• E-mail to services@bscinc.com
• Mail to Benefit Service Center, Inc., 9500 Topanga
Canyon Blvd, Chatsworth, CA 91311
A marriage certificate is needed to add a spouse and a birth
certificate is needed to add a dependent up to the age of 26. For
domestic partner coverage, an affidavit must be submitted. For an
affidavit call the Benefit Service Center at 800-842-6635. If the
change form is received prior to the 15th of the month, the effective
date of dependent coverage will be the first day of the following
month. If received after the 15th of the month, the effective date
of dependent coverage will be the first day of the second month
following receipt.
To use the Dental Net Plan, you and/or your dependents must go to
a dentist who is affiliated with this plan. You cannot go to a dentist
who is not in the plan. If you do not select a dentist, Anthem Blue
Cross will select a dentist for you. After enrolling, you will receive
an Anthem Blue Cross ID card which will indicate the name of your
assigned dentist or dental group. If you wish to switch to a different
dentist than originally assigned, you may call Anthem Blue Cross
Customer Service at 800-627-0004 to request a change to another
dentist in your area that is within the Dental Net provider network.
In addition, you may request an Evidence of Coverage booklet
by contacting the Benefit Service Center at 800-842-6635 or visit
www.mybenefitchoices.com/ihss. This booklet explains the
exclusions and limitations as well as the full range of covered
services.
San Mateo County IHSS Workers’ Insurance Enrollment Information • [ 6 ]

Vision Insurance
For more information go to www.mybenefitchoices.com/ihss.
AIG/Medical Eye Services (MES) provides your vision benefits.
This plan provides eye care as well as eyeglasses. A summary of
vision benefits is included on the next page.
To find an MES eye care provider, please call 800-877-6372 or
visit www.mesvision.com to locate an eye care professional. You
have the option to go to a non-MES provider but you may pay more
out of pocket costs.
To enroll your eligible dependent(s) on the vision plan, you are
required to complete an AIG Individual Application for Group
Vision Coverage form and an Authorization for Direct Automatic
Bill Payment form. THE APPLICATION AND BILL PAYMENT
FORM MUST BE SUBMITTED WITHIN 90 DAYS OF YOUR
INITIAL ENROLLMENT DATE. Call the Benefit Service Center
at 800-842-6635 to request the form. Once received, send the
completed forms back to the Benefit Service Center by one of the
following:
• Fax to 818-678-0030
• E-mail to services@bscinc.com
• Mail to Benefit Service Center, Inc., 9500 Topanga
Canyon Blvd, Chatsworth, CA 91311
After enrolling, you will receive an MES ID card which will
indicate your effective date of coverage and plan information.
A marriage certificate is needed to add a spouse and a birth
certificate is needed to add a dependent up to the age of 26. For
domestic partner coverage, an affidavit must be submitted. For an
affidavit, call the Benefit Service Center at 800-842-6635.
If the application is received prior to the 15th of the month, the
effective date of dependent coverage will be the first day of the
following month. If received after the 15th of the month, the
effective date of dependent coverage will be the first day of the
second month following receipt.
For vision coverage issues, please contact the Benefit Service
Center at 800-842-6635.
For more information go to www.mybenefitchoices.com/ihss.
San Mateo County IHSS Workers’ Insurance Enrollment Information • [ 7 ]

Medical Eye Services/AIG
Vision Plan Benefit Summary
San Mateo County
Public Authority
Vision Service
If you go to a
MES Provider
If you go to a
Non-MES Provider
How often you may
go for this service
Vision Exam
Amount Paid
by Plan
100%
Amount Paid
by Plan
$40
Once Every 12 Months
From the Date of
Service
Standard Eyeglass
Lenses (Glass, Plastic
up to 61mm)
Single Vision
Bifocal
Trifocal
Lenticular
Amount Paid
by Plan
100%
100%
100%
100%
Amount Paid
by Plan
$40
$60
$80
$125
Once Every 12 Months
From the Date of
Service
Eyeglass Frames
Amount Paid
by Plan
Up to $130
Retail Value
Amount Paid
by Plan
$45
Once Every 12 Months
From the Date of
Service
Contact Lenses
Cosmetic
Medically Necessary
Amount Paid
by Plan
Up to $130
100% with
Authorization
from MES
Amount Paid
by Plan
$120
$210
Once Every 12 Months
From the Date of
Service In lieu of
eyeglass lens and
frame benefi t
Loss of Sight Benefit – If, within 180 days of the date of an accident that causes an injury to an
insured person, such injury results in any loss of sight, the maximum benefit amount will be $12,500
for loss of sight of one eye or $25,000 for loss of sight of both eyes.
This is a brief summary of your vision coverage. For a detailed description of your coverage, please
see the documents that you will receive from MES/AIG.
San Mateo County IHSS Workers’ Insurance Enrollment Information • [ 8 ]

Dental Net ®
2000 Series - Plan 2500
Anthem Blue Cross is committed to
providing you with great dental care options
Dental care is an important part of your comprehensive health
care coverage and well-being.
Anthem Blue Cross knows being protected with dental coverage
is an important safeguard for you and your family. We have been
dedicated to providing you and your family with dental coverage
for more than thirty years.
Diagnostic and preventive services are the key to maintaining
good dental health. Dental coverage is designed to assure that
you receive regular preventive care. With routine examinations,
minor dental problems can be diagnosed and treated before
major, more costly problems occur.
Anthem Blue Cross’ Dental Net plan can be instrumental in your
long-term dental health.
Dental Net is a dental HMO that offers one of the most extensive
networks of quality dentists in California.
With Dental Net there are no deductibles and no copayments for
most diagnostic or preventive services, which keeps your outof-pocket
expenses to a minimum.
Simply select the office and primary dentist that is most
convenient to your home or work. Your selected dental office
will provide all routine dental services and arrange for any
specialty care you may need.
Because each eligible family member may choose his or her
own dentist, you and your family will enjoy greater flexibility
and freedom of choice.
San Mateo County IHSS Workers’ Insurance Enrollment Information • [ 9 ]

Dental Net Advantages
Some important advantages when using your Dental Net plan
include:
• Easy to use
• Most diagnostic and preventive care at no cost to
members
• No claim forms
• No deductibles or annual maximums for most dental
services
• Orthodontic coverage
• Referral to specialists from your primary dentist
Your Dental Net Plan
You can find an Anthem Blue Cross Dental Net dentist or one
can be assigned to you. If you would like to switch dentists or
your dependent needs to choose a dentist, here are some tools to
help you find a participating dental office and primary dentist:
1. Check online at Anthem Blue Cross website:
www.anthem.com/ca
2. You may request a directory or a list of providers in
your area by calling the toll-free customer service
number for Anthem Blue Cross at 800-627-0004
With the exception of out-of-area emergency services and
certain specialty services, all of your dental care needs will be
provided by, or coordinated through, your selected dental office
and primary dentist.
After enrollment, you will receive a member ID card listing
your selected participating dental office and the phone number.
San Mateo County IHSS Workers’ Insurance Enrollment Information • [ 10]

Your First Visit
Because preventive dental care is so important, Dental Net
provides benefits at no cost for X-rays and two teeth cleanings per
year. Soon after enrollment, you should call your participating
dental office for an initial diagnostic examination. X-rays will
usually be taken at this time to determine the overall condition of
your teeth. Through routine check-ups, minor dental problems
can often be diagnosed and treated before they become major
problems.
We encourage you to call your participating dental office
whenever you need dental care. Please note that Dental Net does
not limit the number of times you can see your dentist, as long
as services are dentally necessary.
Customer Service
An Anthem Blue Cross Customer Service representative is
available to answer your dental questions and inquiries at 800-
627-0004.
Dental Net Benefits
There is no deductible with Dental Net, however, some
procedures require a copayment that you will need to pay at the
time of service. Please refer to the copayment amounts listed on
the chart on pages 12 through 14.
Continuing Coverage
As required by federal law, certain restrictions and conditions
apply to the right to continue coverage and are described in your
Evidence of Coverage (EOC).
San Mateo County IHSS Workers’ Insurance Enrollment Information • [ 11 ]

Covered Services Per Member Copay Covered Services Per Member Copay
Diagnostic
0120 – Periodic Oral Evaluation
0140 – Limited Oral Evaluation
– Problem focused
0150 – Comprehensive Oral Examinations
0160 – Detailed and Extensive Oral Evaluation
0170 – Re-evaluation – Limited Problem
Focused (not post-operative visit)
– Office Visit – per patient per office
visit in addition to patient copays
0210 – X-rays – intraoral – complete series
(including bitewings)
0220 – X-rays – intraoral – periapical – first film
0230 – X-rays – intraoral – pericapical
– each additional film
0240 – X-rays – intraoral – occlusal film
0270 – X-rays – bitewing – single film
0272 – X-rays – bitewings – two films
0274 – X-rays – bitewings – four films
0277 – X-rays – vertical bitewings
0330 – X-rays – panoramic film
0460 – Pulp Vitality Tests
0470 – Diagnostic Casts
9310 – Consultation
Preventive
1110 – Prophylaxis – adult¹
1120 – Prophylaxis – child¹
1201 – Topical Fluoride
– child (including prophylaxis)
1203 – Topical Fluoride
– child (excluding prophylaxis)
1204 – Topical Fluoride
– adult (excluding prophylaxis)
1205 – Topical Fluoride
– adult (including prophylaxis)
1330 – Oral Hygiene Instructions
1351 – Sealants – per tooth
1510 – Space Maintainers – fixed – unilateral
1515 – Space Maintainers – fixed – bilateral
1520 – Space Maintainers – removable – unilateral
1525 – Space Maintainers – removable – bilateral
1550 – Recementation of Space Maintainer
No Copay
No Copay
No Copay
No Copay
No Copay
No Copay
No Copay
No Copay
No Copay
No Copay
No Copay
No Copay
No Copay
No Copay
No Copay
No Copay
No Copay
No Copay
No Copay
No Copay
No Copay
No Copay
No Copay
No Copay
No Copay
$5
$40
$40
$50
$50
$5
Restorative
2110 – Fillings, amalgams – one surface, primary No Copay
2120 – Fillings, amalgams–two surfaces, primary No Copay
2130 – Fillings, amalgams
– three surfaces, primary
No Copay
2131 – Fillings, amalgams
– Four or more surfaces, primary No Copay
2140 – Fillings, amalgams
– one surface, permanent
No Copay
2150 – Fillings, amalgams
– two surfaces, permanent
No Copay
2160 – Fillings, amalgams
– three surfaces, permanent
No Copay
¹For the third cleaning in a 12 month period, the copay is 80% of the dentist’s usual fee.
Restorative (continued)
2161 – Fillings, amalgams
– four or more surfaces, permanent
2330 – Resin – one surface, anterior
2331 – Resin – two surfaces, anterior
2332 – Resin – three surfaces, anterior
2335 – Resin – four or more surfaces, anterior,
or involving incisal angle
2336 – Resin – based composite, anterior – primary
2337 – Resin – based composite, anterior – permanent
2380 – Resin – one surface, posterior – primary
2381 – Resin – two surfaces, posterior – primary
2382 – Resin – three or more surfaces,
posterior – primary
2385 – Resin – one surface, posterior – permanent
2386 – Resin – two surfaces, posterior – permanent
2387 – Resin – three or more surfaces,
posterior – permanent
2388 – Resin – based composite, four or more
surfaces, posterior – permanent
Endodontics
3110 – Pulp Cap – Direct
(excluding final restoration)
3120 – Pulp Cap – Indirect
(excluding final restoration)
3220 – Therapeutic Pulpotomy
(excluding final restoration)
3221 – Gross pulp debridement
primary and permanent teeth
3310 – Anterior Root Canal Therapy – 1 canal
(excluding final restoration)
3320 – Bicuspid Root Canal Therapy – 2 canals
(excluding final restoration)
3330 – Molar Root Canal Therapy – 3 canals
(excluding final restoration)
3332 – Incomplete Endodontic Therapy
(inoperable or fractured tooth)
3346 – Retreatment of previous anterior
root canal therapy
3347 – Retreatment of previous bicuspid
root canal therapy
3348 – Retreatment of previous molar
root canal therapy
3410 – Apicoectomy/periradicular surgery – anterior
3421 – Apicoectomy/periradicular surgery – bicuspid
(first root)
3425 – Apicoectomy/periradicular surgery – molar
(first root)
3426 – Apicoectomy/periradicular surgery
– each additional tooth
3430 – Retrograde filling – per root
3910 – Surgical procedure for isolation of tooth
with rubber dam
3950 – Canal preparation and fitting of
preformed dowel or post
No Copay
No Copay
No Copay
No Copay
San Mateo County IHSS Workers’ Insurance Enrollment Information • [ 12 ]
$10
$50
$60
$30
$40
$50
$50
$65
$75
$85
No Copay
No Copay
$5
$23
$100
$125
$240
$45
$110
$135
$150
$110
$110
$110
$40
$100
No Copay
No Copay

Covered Services Per Member Copay Covered Services Per Member Copay
Periodontics
Prosthodontics (continued)
4210 – Gingivectomy/Gingivoplasty – per quadrant
4211 – Gingivectomy/Gingivoplasty – per tooth
4220 – Gingival curettage, surgical – per quadrant
4260 – Osseous surgery – per quadrant
$85
$22
$25
$5
4341 – Periodontal scaling/root planing – per quadrant
4355 – Full mouth debridement to enable
comprehensive periodontal evaluation/diagnosis
4910 – Periodontal maintenance procedures
(following active therapy)
Oral Surgery
7110/– Single extraction/each
7120 additional tooth
7130 – Root Removal – exposed roots
7210 – Surgical removal of erupted tooth
7220 – Removal of impacted tooth – soft tissue
7230 – Removal of impacted tooth – partial bony
7240 – Removal of impacted tooth – completely bony¹
7241 – Removal of impacted tooth – completely bony,
with unusual surgical¹
7250 – Surgical removal of residual tooth roots
(cutting procedure)
7285 – Biopsy of oral tissue – hard (bone, tooth)²
7286 – Biopsy of oral tissue – soft (all others)²
7310 – Alveoplasty in preparation for dentures,
with extractions – per quadrant³
7320 – Alveoplasty in preparation for dentures,
without extractions – per quadrant³
7510 – Incision and drainage of abscess
– intraoral soft tissue
Prosthodontics
2510 – Inlay – metallic– one surface⁴
2520/6520 – Inlay – metallic– two surfaces⁴
2530/6530 – Inlay – metallic– three or more surfaces⁴
2542 – Onlay – metallic– two surfaces⁴
2543/6543 – Onlay – metallic– three surfaces⁴
2544/6544 – Onlay – metallic– four or more surfaces⁴
2740 – Crown – porcelain/ceramic substrate
2750 – Crown – porcelain fused to high noble metal⁴
2751 – Crown – porcelain fused to predominantly
base metal
2752 – Crown – porcelain fused to noble metal⁴
2780 – Crown – cast high noble metal⁴
2781 – Crown – cast high predominantly base metal
2782 – Crown – cast noble metal⁴
2783 – Crown – porcelain/ceramic
2790 – Crown – full cast high noble metal⁴
2791 – Crown – full cast predominantly base metal
2792 – Crown – full cast noble metal⁴
2810 – Crown – cast metallic⁴
2910 – Recement inlay
$180
$25
$25
$25
No Copay
No Copay
$35
$40
¹Independent procedures copays cannot be combined.
²Histopathological exam is not included and is not benefited.
³In preparation for dentures.
⁴Plus actual costs for noble/high (precious) metal not to exceed $100
⁵Either type of denture is an acceptable restoration; however, Dental Net benefits the first one placed, not both.
$75
$85
$85
$55
$30
$30
$70
$85
$25
$70
$80
$90
$140
$140
$140
$225
$200
$200
$200
$200
$200
$200
$200
$200
$200
$200
$200
$5
2920 – Recement crown
2930/– Prefabricated stainless steel crown
2931 – primary/permanent tooth (provisional)
2932 – Prefabricated resin crown (provisional)
2940 – Sedative filling
2950 – Core buildup, including any pins
2951 – Pin retention – per tooth, in addition
to restoration
2952 – Cast post and core in addition to crown
2953 – Each additional cast post (same tooth)
2954 – Prefabricated post and core in addition to crown
2955 – Post removal (not in conjunction with
endodontic therapy)
2957 – Each additional prefab post (same tooth)
2970 – Temporary crown (fractured tooth)
6210 – Pontic – cast high noble metal⁴
6211 – Pontic – cast predominantly base metal
6212 – Pontic – cast noble metal⁴
6240 – Pontic – porcelain fused to high noble metal⁴
6241 – Pontic – porcelain fused to predominantly
base metal
6242 – Pontic – porcelain fused to noble metal⁴
6245 – Pontic – porcelain/ceramic
6740 – Crown – porcelain/ceramic
6750 – Crown – porcelain fused to high noble metal⁴
6751 – Crown – porcelain fused to predominantly
base metal
6752 – Crown – porcelain fused to noble metal⁴
6780 – Crown – cast high noble metal⁴
6781 – Crown – cast high predominantly base metal
6782 – Crown – cast noble metal⁴
6783 – Crown – porcelain/ceramic
6790 – Crown – full cast high noble metal⁴
6791 – Crown – full cast predominantly base metal
6792 – Crown – full cast noble metal⁴
6930 – Recement fixed partial denture
6970 – Cast post and core in addition to fixed
partial denture retainer
6971 – Cast post as part of fixed
partial denture retainer
6972 – Prefabricated post and core in addition to
fixed partial denture retainer
6973 – Core buildup for retainer, including any pins
6976 – Each additional cast post (same tooth)
6977 – Each additional prefab post (same tooth)
5110/– Complete denture⁵
5120 (maxillary/mandibular)
5130/– Immediate denture⁵
5140 (maxillary/mandibular)
5211/– Partial denture (maxillary/mandibular)
5212 – resin base (including clasps, rests)
San Mateo County IHSS Workers’ Insurance Enrollment Information • [ 13]
$20
$20
No Copay
$20
$10
$40
No Copay
$40
$15
No Copay
$20
$200
$200
$200
$200
$200
$200
$225
$225
$200
$200
$200
$200
$200
$200
$200
$200
$200
$200
$5
$40
$40
$40
$20
No Copay
No Copay
$225
$240
$275

Covered Services Per Member Copay
Prosthodontics (continued)
5213/– Partial denture (maxillary/mandibular) $275
5214 – cast metal framework with resin denture bases
5410/– Adjust complete denture
5411 (maxillary/mandibular)
$10
5421/– Adjust partial denture
5422 (maxillary/mandibular)
$10
5510 – Repair broken complete denture base $25
5520 – Replace missing or broken teeth
– complete denture (each tooth)
$25
5610 – Repair resin denture base
$25
5620 – Repair cast framework
$45
5630 – Repair or replace broken clasp
$30
5640 – Repair broken teeth – (per tooth)
$25
5650 – Add tooth to existing partial denture
$25
5660 – Add clasp to existing partial denture
$45
5710/– Rebase complete denture
5711 (maxillary/mandibular)
$80
5720/– Rebase partial denture
5721 (maxillary/mandibular)
$80
5730/– Complete denture reline – chairside
5731 (maxillary/mandibular)
$25
5740/– Partial denture reline – chairside
5741 (maxillary/mandibular)
$25
5750/– Complete denture reline – laboratory
5751 (maxillary/mandibular)
$50
Covered Services Per Member Copay
Prosthodontics (continued)
5760/– Partial denture reline – laboratory
5761 (maxillary/mandibular)
$50
5820/– Interim partial denture
5821 (maxillary/mandibular)
$110
5850 – Tissue conditioning – per denture
$35
5851 – Tissue conditioning – lower – per denture $35
Other Services
Out-of-area emergency
(limited to $50 benefit)
9110 – Palliative emergency treatment of dental pain
No Copay; all charges over $50
– minor procedure
9211 – Regional block anesthesia
9215 – Local anesthesia
9430 – Office visits for observation
(during regularly scheduled hours)
9440 – Office visits – after hours
9630 – Other drugs and/or medicaments, (by report)¹
– Broken appointments (less than 24 hours)
$5
No Copay
No Copay
No Copay
$45
$15
$25
Orthodontics
24 months of usual and customary exclusive of records and
retention fees
8080 – Child through age 17
$1,600
8090 – Adult age 18 and over
$1,600
8660 – Pre-orthodontic visits and treatment plan $300
8680 – Orthodontic retention
$275
¹Not prescription drugs.
This Summary of Benefits is a brief review of benefits. Please refer to the Combined Evidence of Coverage and
Disclosure Form, which explains the exclusions and limitations, as well as the full range of covered services of the
plan, in detail.
San Mateo County IHSS Workers’ Insurance Enrollment Information • [ 14]

Dental Net 2000 Series Exclusions & Limitations
LIMITED SERVICES
Unauthorized Services. Dental services must be received from the member’s participating dental
office unless an exception is specifically authorized in writing by the member’s participating dental
office and/or Dental Net.
Oral Exams. Oral exams are limited to two per calendar year.
Prophylaxis. Procedures are limited to two treatments during each calendar year. If a third
prophylaxis is provided within the calendar year, it will be subject to a 80% copayment based on
the participating dentist’s usual fee.
Periodontal Procedures. Periodontal scaling and root planing and/or gingival curettage are
limited to one course of therapy per quadrant during any 12-month period. Full mouth debridement
to enable comprehensive periodontal evaluation and diagnosis is limited to one course of
treatment per lifetime.
Prosthodontic Replacements. Partial dentures are not eligible for replacement within five years
of original placement unless required as a result of additional tooth loss which cannot be restored
by modification of the existing partial denture. Crowns, bridges, inlays and/or complete dentures
are not eligible for replacement within five years of original placement.
Sealants. Sealants are limited to children under 16 years of age for permanent molars,
unrestored. Treatment is limited to once every 36 months per tooth.
Denture Relines. Complete and/or partial denture relines or rebases are limited to one per
denture during any 12-month period.
Precious Metals. The use of alloys with 25% or more noble metal content for any restorative
procedure is considered optional and, if used, the additional cost for such alloy should not exceed
$100 and will be the member’s responsibility.
Impactions. Removal of impacted teeth is limited to impactions which show radiographic
evidence of a pathologic condition or for which the member experiences unresolved symptoms of
infection, swelling or chronic pain.
Pediatric Annual Maximum. Pediatric dental services are limited to $500 per calendar year for
each child. Referral to a pedodontist will be considered for children to the age of 5. Charges in
excess of $500 will be the member’s financial responsibility.
Porcelain on molars. If porcelain to metal crowns are placed on molars, an additional charge of
$75 per tooth will be charged.
Seven (7) or more crowns. If a treatment plan involves seven (7) or more crowns and/or fixed
bridge units, an additional charge of $125 per tooth or artificial tooth will be charged for all teeth
and artificial teeth.
SERVICES NOT COVERED
Not Acceptable Services. Any service or supply which we determine not to be an acceptable
service, as specified in the Evidence of Coverage (EOC).
Cosmetic Services. Dental services necessary solely for cosmetic reasons including, but not
limited to, bleaching of non-vital discolored teeth, veneers and all other cosmetic procedures
(unless specifically shown as a covered benefit).
Workers’ Compensation. Any condition for which benefits of any nature are recovered or found
to be recoverable, whether by adjudication or settlement, under any workers’ compensation or
occupational disease law, even if the member does not claim those benefits.
Government Programs. Care or treatment which is obtained from or for which payment is made
by any federal, state, county, municipal or other government agency, including any foreign
government.
Fractures or Dislocations. Treatment of jaw fractures or dislocations.
Hospital Charges. Hospital and associated physician charges of any kind or charges for any
dental treatment which cannot be performed in the participating dental office.
Member Health Limitations. Charges for any dental treatment, which because of the member’s
general health or mental, emotional, behavioral, or physical limitations, cannot be performed in the
participating dental office.
Lost or Stolen Dentures or Appliances. Replacement of lost crowns, lost or stolen dentures,
bridgework or other dental appliances.
Services Provided Before or After the Term of the Member’s Coverage. Dental treatment or
expenses incurred in connection with any dental procedure started prior to the member’s effective
date. Dental treatment or expenses incurred after termination of the member’s coverage, as
specified as covered in the Evidence of Coverage (EOC).
Treatment by a Non-Participating Dentist. Any corrective treatment required as a result of
dental services performed by a non-participating dentist while this coverage is in effect, and any
dental services started by a non-participating dentist will not be the responsibility of the
participating dental office or Dental Net for completion.
Cysts and Neoplasms. Histopathological exams and/or the removal of tumors, cysts, neoplasms
and foreign bodies.
Congenital (Hereditary) or Developmental Malformations. Dental treatment or expenses
incurred in connection with the correction of congenital or developmental malformations including,
but not limited to, enamel hypoplasia, fluorosis, anodontia, supernumary or impacted teeth other
than third molars.
Surgical Services. Tooth implantation or transplantation, orthognathic surgery, soft tissue or
osseous grafts, hemisection or root amputation, apexification, vestibuloplasty or ostectomy
procedures.
Prosthetic Services Age Limitations. Inlays, onlays, crowns, fixed bridges, or removable cast
partials for members under 16 years of age. Space maintainers for members over age sixteen.
Experimental or Investigative Procedures. Procedures which are considered experimental or
investigative or which are not widely accepted as proven and effective procedures within the
organized dental community.
Implants. Dental procedures and charges incurred as part of implants or the removal of same.
Fixed or removable prosthetics in conjunction with implants. Prophylaxis on implants.
Vertical Dimension and Attrition. Dental treatment or procedures (other than those for
replacement of structure lost due to dental decay) required in conjunction with opening a bite or
replacing tooth structure lost by wear, erosion or abrasion or due to bruxism. (Does not apply to
alteration by removable prosthodontics.)
Periodontal Splinting. Dental treatment or expenses incurred in connection with periodontal
splinting.
Treatment of the Joint of the Jaw. Diagnosis or treatment by any method of any condition
related to the temporomandibular (jaw) joint or associated musculature, nerves and other tissues.
General Anesthesia. General anesthesia, inhalation sedation, intravenous sedation or
intramuscular sedation.
Procedures Not Specified as Covered. Any procedure not specifically listed as a covered
service.
Drugs or Dispensing of Drugs. Plan does not cover prescription drugs as a dental benefit.
Questionable, Guarded or Poor Prognosis. Teeth with questionable, guarded or poor prognosis
are not covered for endodontic treatment, periodontal surgery or crown and bridge. Dental Net will
allow for observation or extraction and prosthetic replacement.
Personalization, Characterization or Precision Attachments. Precision attachments,
characterization or personalization of dentures is excluded.
Crown Lengthening. Crown exposure, ligation and crown lengthening are not covered.
Removal of Third Molars. Immature erupting third molars are not covered for extraction,
i.e., tooth proceeding through a normal eruption process.
Primary Restorations. Gold, porcelain or resin fillings on primary teeth are excluded.
Denture Replacement. Dentures, full or partial-replacements will be made only if existing denture
is five (5) years old, is unsatisfactory and cannot be made serviceable.
ORTHODONTIC EXCLUSIONS AND LIMITATIONS
ORTHODONTIC LIMITATIONS
Authorized Orthodontic Services. Orthodontic services must be received from the member’s
participating orthodontic office as specifically authorized and referred by Dental Net in writing.
Lifetime Maximum. Orthodontic treatment is limited to one full case (up to 24 months of standard
orthodontic care) during the member’s lifetime.
Loss of Coverage During Orthodontic Treatment. If the member’s coverage under the
plan ends, for any reason, while the member is still receiving orthodontic treatment during the
24 month treatment period, the member and NOT Dental Net will be responsible for the remainder
of the cost for that treatment, at the contracted fee for the remaining number of months of
treatment.
Orthodontic consultation/Observation Fees. If treatment is not required or the member
chooses not to start treatment after a diagnosis and consultation have been completed by
the provider, the member may be charged a consultation fee of $30 in addition to diagnostic
record fees.
Orthodontic Retention Phase of Care. Retention services include initial fabrication,
placement, observation, and adjustments of passive retention appliances for a 12-month period.
The retention services fee of $275 is the member’s responsibility and is payable at the beginning
of the retention phase of treatment. Retention services fees are subject to review and modification
on an annual basis.
Orthodontic Services in Excess of 24 Months of Active Care. The member is required to pay
the participating orthodontist of $55 per month for each additional month of standard active
orthodontic treatment provided beyond the 24 month period, but before the retention phase of
treatment begins.
ORTHODONTIC EXCLUSIONS
Changes in Treatment. Changes in treatment necessitated by an accident of any kind or patient
noncompliance.
Myofunctional Therapy. Myofunctional therapy and related services. (Myofunctional therapy
involves the use of muscle exercises as an adjunct to orthodontic mechanical correction of
malocclusion.)
Orthodontic Retreatment. The retreatment of a previously treated orthodontic case (whether
treated under this coverage, at fee-for-service, or under another benefit plan) is not covered.
Services Provided Before or After the Term of This Coverage. Orthodontic treatment begun
prior to the member’s effective date or after the termination of coverage.
Other Orthodontic Services. Services for braces, other orthodontic appliances, or orthodontic
services, except as specifically stated in this coverage.
Orthodontic Treatment Incidental to Surgical Procedures. Orthodontic treatment in
conjunction with oral surgical procedures including, but not limited to, orthognatic surgery.
Phase I Orthodontics/Orthopaedic/Orthodontic Treatment. Any Phase I treatment or
orthopaedic/orthodontic treatment which may be deemed advantageous or necessary by the
participating orthodontist prior to the 24 months or standard active treatment. Orthodontic
treatment for malocclusions which, in the opinion of the participating orthodontist will not produce
beneficial results.
Replacement of Orthodontic Appliances. Replacement of lost or stolen orthodontic appliances
or repair of orthodontic appliances broken due to the member’s negligence.
Special Orthodontic Appliances. Special types of orthodontic appliances which are considered
cosmetic including, but not limited to, lingual or “invisible” braces, sapphire or clear braces, or
ceramic braces.
Surgical Procedures Incidental to Orthodontic Treatment. Surgical procedures incidental to
orthodontic treatment including, but not limited to, extraction of teeth solely for orthodontic
reasons, exposure of impacted teeth, ligation, correction of micrognathia or macrognathia, or
repair of cleft palate.
T.M.J. or Hormonal Imbalance Orthodontic Services. Treatment related to the joint of the jaw
(temporomandibular joint, TMJ) and/or hormonal imbalance.
Third Party Liability. Anthem Blue Cross is entitled to reimbursement of benefits paid if the
member recovers damages from a legally liable third party.
Coordination of Benefits. The benefits of this plan may be reduced if the member has any other
group dental coverage so that the services received from all group coverages do not exceed 100%
of the covered expense.
Anthem Blue Cross is the trade name of Blue Cross of California. Independent Licensee of
the Blue Cross Association. ® ANTHEM is a registered trademark. ® The Blue Cross name
and symbol are registered marks of the Blue Cross Association.
San Mateo County IHSS Workers’ Insurance Enrollment Information • [ 15]