2019 Summary of UCare Dental Benefits
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FOR COUNTY REFERENCE ONLY 2019 Summary of UCare Dental Benefits UCare Prepaid Medical Assistance Program (PMAP) UCare MinnesotaCare UCare Minnesota Senior Care Plus (MSC+) UCare Minnesota Senior Health Options (MSHO) UCare Special Needs BasicCare (SNBC) UCare Special Needs BasicCare + Medicare (SNBC + Medicare) UCare offers a variety of dental care services to UCare members. This summary presents the benefits by UCare plan.
For PMAP, MinnesotaCare, SNBC, MSC+ and MSHO Members
UCare Dental Connection UCare’s Mobile Dental Clinic
The UCare Dental Connection helps our UCare is proud to be the first Minnesota health
members manage their dental care with one simple plan to own and operate a Mobile Dental Clinic.
phone call. The clinic is a specially designed, wheelchair-
A one-stop-shop, the UCare Dental Connection can accessible, 43-foot “dentist’s office on wheels.” It has
help members: three dental chairs, state-of-the-art instruments,
• Find a provider or dental home chair-side digital radiography and an electronic
health record system.
• Schedule dental appointments, including
appointments for follow up and specialty care The Mobile Dental Clinic offers dental check-ups,
cleaning and simple restorative care to UCare
• Coordinate transportation to dental members who have limited access to quality
appointments dental care.
• Coordinate interpreter services for dental All care is provided by faculty-supervised dental,
appointments dental hygiene and dental therapy students from
• Answer questions related to dental care the University of Minnesota School of Dentistry,
UCare’s Mobile Dental Clinic (MDC) partner.
Members should call UCare Dental
Connection directly at Check the clinic’s location schedule at
651-768-1415 or 1-855-648-1415 toll free ucare.org/mdc.
TTY: 1-800-916-9514 toll free Members can make appointments by calling the
7 am – 7 pm, Monday through Friday University of Minnesota School of Dentistry at
1-866-451-1555 toll free
County staff working with UCare members should
call our Team Representative in your county or TTY: 1-800-627-3529 toll free
email UCareCountyRelations@ucare.org. 8 am to 4:30 pm, Monday-Friday
*Schedule is subject to change.
Endodontics (Root canals) on anterior teeth and
premolars only
Periodontics:
• Gross removal of plaque and tartar once every
five years
• Scaling and root planing once every two years,
only when provided in an outpatient hospital or
freestanding ASC
Prosthodontics:
• Removable prostheses (dentures and partials)
once every six years per dental arch
Covered Dental Services
• Replacement of removable prostheses
Diagnostic services: if misplaced, stolen, or damaged due to
• Comprehensive exam every five years circumstances beyond the enrollee’s control
• Periodic exam once per calendar year • Relines, repairs, and rebases of removable
• Problem-focused exams (once per day, prostheses (dentures and partials)
per facility) Oral surgery limited to extractions, biopsies, and
• X-rays are limited to: incision and drainage of abscesses
• Bitewing once per calendar year Orthodontic (children up through age 20—
coverage based on significant disfigurement,
• Single X-rays for diagnosis of problems impairment of function)
• Panoramic: Additional general services:
>>Once every five years • Treatment for pain (once per day)
>>As medically necessary for diagnosis and
follow-up of oral and maxillofacial conditions • General anesthesia, only when provided in an
and trauma outpatient hospital or freestanding ASC
>>Once every two years in limited situations • Extended care facility/house calls in certain
• Full-mouth X-rays once every five years, only extended care settings
when provided in an outpatient hospital or • Oral or IV sedation if the covered dental service
freestanding Ambulatory Surgery Center (ASC) cannot be performed safely without it
Preventive services: • Behavioral management when necessary to
• Cleaning up to four times per calendar year ensure that a covered dental service is correctly
if medically necessary and safely performed
• Fluoride varnish once per year (Children up to Pregnant women and children receive enhanced
age 20 and pregnant women are eligible for dental care. Please call UCare Dental Connection
flouride varnish once every six months when at 1-855-648-1415 (toll free) or 651-768-1415
provided at a dentist’s office. Children receiving for more details.
flouride varnish at their doctor’s office or other
non-dental setting are eligible for as many
applications as indicated per DHS Child & Teen For PMAP, MinnesotaCare, SNBC,
Checkup guidelines.)
Restorative services:
SNBC + Medicare and MSC+
• Fillings members
• Sedative fillings for relief of pain UCare offers an extra dental check-up per year,
• Crowns (only for pregnant women and children, beyond what’s covered by Medical Assistance.
if medically necessary). For MSHO crown
coverage information, see “For UCare’s MSHO Covered Dental Services, continued on next page
Members.”
For MSHO Members
In addition to Medicare- and Medicaid-covered dental benefits, MSHO
members have additional dental coverage for preventive and restorative
dental services that are not covered by Medical Assistance. Members
must receive these services from a network dentist.
Below is a list of preventive and restorative codes that may be accessed: New in 2019
• Scaling and root planing (D4341 and D4342) MSHO and Connect +
-- Once every two years and only in an office setting. The member Medicare members are
must have pocket depths of 4mm or greater and documented eligible for an electric
bone loss visible on x-rays. toothbrush.* Members
• Additional dental exam (D0120) may call the Customer
-- One additional per calendar year. Services number on their
• Molar root canal (D3330) UCare member ID card for
-- One per tooth per lifetime. more information.
• Root canal re-treatment (D3346, D3347, D3348) * One electric toothbrush
-- Rule: One re-treat per tooth per lifetime. Covered only if billed 24 per lifetime; one package
months after original root canal. or three replacement
• Full mouth series (x-ray) (D0210) heads per year.
-- Rule: Once per five years
• Periodontal maintenance (D4910)
-- Four times per calendar year.
-- Porcelain-Fused-to-Metal
• PFM crown (D2750)
-- One per calendar year.
Members will be informed of the portion of the cost they will need to pay. Certain limitations apply.
CONTACT INFORMATION
Members UCare County Team Reps (see map)
Delta Dental Customer Services ucare.org > Counties
651-768-1415 or
1-855-648-1415 toll free UCareCountyRelations@ucare.org
UCare Mobile Dental Clinic County Staff
appointments Call Delta Dental Government
1-866-451-1555 toll free Programs Access Unit
TTY 1-800-627-3529 toll free 1-866-303-8138 toll free or 651-994-5198
This reference document was prepared by UCare staff for county partners
across Minnesota. Information is current as of Jan. 1, 2019. U5031 (02/19)You can also read
