Benefits For Children Birth-20 (Covered CT 19-20)

Your Dental Plan with the Connecticut Dental Health Partnership offers coverage for the following benefits:

Important to note:

HUSKY Health and Covered CT cover certain MEDICALLY necessary dental services. For HUSKY Health, children are considered all individuals under the age of 21. For Covered CT, ages 19 and 20.
Not all dental procedures are covered benefits, and certain covered dental services require prior authorization by your dentist.
Covered services are provided at dental providers in the CTDHP network which is part of the HUSKY Health network. You may have to pay for services if the service is provided by a dentist that does not participate in the CTDHP network.
Covered services are provided at no cost to you. You will have to pay for services if you choose to have a service that is not included in the HUSKY Health plan.
If you wish to speak to a member services representative, please call the Connecticut Dental Health Partnership (CTDHP) toll free 1-855-CT DENTAL (1-855-283-3682). We are available Monday through Friday, from 8:00 a.m. to 5:00 p.m.

Care Category	Description	Benefits and Limitations
Diagnostic	Oral examination or screening.	Periodic Exam: 2 times per year Problem Focused Exam: 4 times per year Comprehensive Exam: once every 3 years
X-Rays	Complete mouth x-rays, periapical x-rays, bitewing x-rays, panoramic x-rays.	Bitewing X-ray: 1 per year Periapical X-rays: 4 per year Complete Mouth Series or Panoramic X-ray: 1 every 3 years
Preventive	Cleaning, fluoride application. Sealants every 5 years; some restrictions apply.	1 every 6 months per member.
Restorative - Fillings	The treatment of tooth decay by the use of silver and/or white fillings.	Fillings are covered once per two years for the same tooth surface. HUSKY B Copay 20%
Restorative - Crowns	The use of gold, semiprecious, or nonprecious metals and/or porcelain to restore a tooth or teeth which cannot be restored with silver or white restorations.	Covered once per five years. Prior authorization required. HUSKY B Copay 33%
Endodontics	The treatment of the diseases of the blood vessels and the nerve of the tooth. Endodontic treatment often involves root canal procedures.	Initial and retreatment root canal procedures covered up to age 21. Prior authorization required. HUSKY B Copay 20%
Periodontics	The treatment of the supporting tissues of the teeth, gums, and underlying bone, with either surgical or nonsurgical procedures (where applicable).	Prior authorization required.
Prosthetics -Removable	The replacement of missing teeth by the use of a removable appliance.	Prior authorization required. Husky B Copay 50%.
Prosthetics - Adjustments & Relines	The repair or modification of existing removable appliances so that they can continue to be serviceable.	Is allowed after 6 months after the initial placement of the denture(s). HUSKY B Copay 20%
Prosthetics - Fixed	The use of gold, semiprecious, or precious metal to replace a missing tooth or teeth. Fixed prosthetics may include bridgework, implants and implant retained crowns and dentures.	Not covered but may be covered in special circumstances with medical necessity.
Extractions	The extraction, either simple or surgical, of either a single tooth or multiple teeth.	Covered for all permanent, baby and extra teeth. Biopsies, bone grafting, alveoloplasty, facial surgery for trauma and inherited facial conditions. Prior authorization is required. Husky B Copay 20% simple extraction or 33% surgical.
Wisdom Tooth Removal and Impactions	The surgical removal of fully erupted teeth when medically necessary or teeth partially or fully covered by gum tissue or bone.	Prior authorization Required. HUSKY B Copay 33%
Oral Surgery	The shaping of bone ridges, the treatment of an abscess, biopsies of soft and hard tissues, reconstructive surgeries etc.	Prior authorization Required. HUSKY B Copay 33%
Orthodontics	The straightening of teeth for significant dental health reasons.	HUSKY A, HUSKY C, HUSKY D Prior Authorization required HUSKY B Limited to recipients under age 19 No Prior Authorization required Allowance - $725.00 Member is responsible for balance up to $3,198.21
Athletic Mouth Guard	Mouthguards are worn over the top row of teeth during sports to help prevent an oral injury. They protect against broken teeth, cut lips, and other damage to the mouth.	Covered one per member, per lifetime for members under 21 who are enrolled in a contact sport. Prior Authorization required. Provider must submit a letter from school or organization where child is enrolled in the sport. HUSKY B Copay 20%
Occlusal “Night” Guards	A removable acrylic appliance intended to relieve temporomandibular joint pain and other effects of grinding the teeth (bruxism). Usually worn at night to prevent grinding during sleep.	Prior Authorization required for members with severe clenching or tooth grinding habits. May be used to treat temporomandibular joint (TMJ) problems. HUSKY B Copay 20%
Deep Sedation/General Anesthesia	Covered for general dental procedures and tooth extractions in children under the age of 9 OR for children under the age of 21 with behavioral related conditions such as autism, cerebral palsy, intellectual delays.	Prior Authorization required.
Inhalation sedation	Nitrous oxide. Covered for children up to the age of 9 without prior authorization OR for children under the age of 21 with behavioral	Prior Authorization required.