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The Oregon Health Plan (OHP)
Dental Benefits (Covered Procedures)
OHP’s Client Handbook on covered services (medical & dental) [pdf]
OHP PLUS BENEFITS – COVERED PROCEDURES
EXAMS
- Each member is limited to one exam every twelve months.
RADIOGRAPHS
- Routine radiographs are limited to once every 12 months, except panoramic and intraoral complete series, which are payable once every five years.
PREVENTIVE SERVICES
- Prophylaxis -- Limited to once every 12 months.
- Topical Fluoride Treatment (Office Procedure) is limited to once every 12 months.
- Sealants are covered for permanent molars only for children 15 or younger.
- Limited to one treatment per tooth every five years except for visible evidence of clinical failure.
- Space Management -- Removable space maintainers will not be replaced if lost or damaged.
RESTORATIONS
Amalgam and Composite:
- Payment for restorations is limited to the maximum restoration fee of four surfaces per tooth.
- All surfaces must be combined and billed one line per tooth using the appropriate code.
- Payment for an amalgam or composite restoration and a crown on the same tooth will be denied.
- Payment is made for a surface once in each treatment episode regardless of the number or combination of restorations.
- Posterior composite restorations will be paid at the same rate as amalgam restorations.
- Replacement restorations are limited to once every five years.
CROWNS
- Acrylic Heat or Light Cured Crowns -- allowed for front permanent teeth only.
- Prefabricated Plastic Crowns -- allowed for front teeth only; permanent or primary.
- Permanent crowns -- allowed for front permanent teeth only. Clients must be 16 or older. Radiographs required.
- Payment for crowns for back teeth, permanent or primary, is limited to stainless steel crowns.
- Crowns are covered only when there is significant loss of clinical crown and no other restoration will restore function.
- Crown replacement is limited to one every five years per tooth.
- Crowns will not be covered in cases of advanced periodontal disease or when a poor crown/root ratio exists for any reason.
ENDODONTICS
- Root canal therapy is not covered for wisdom teeth
PERIODONTICS
- Gingivetomy or Gingivoplasty
- Covered for severe gingival hyperplasia where enlargement of gum tissue occurs that prevents access to oral hygiene procedures, e.g., dilantin hyperplasia.
- Gingival Flap Procedure
- Allowed once every three years unless there is a documented medical/dental indication.
- Perio Scaling and Root Planing
- Allowed once every two years.
- Perio Maintenance Procedure
- Allowed once every six months.
REMOVABLE PROSTHODONTICS
- Removable cast metal prosthodontics and full dentures are limited to clients 16 or older.
- Replacement of dentures and partials is limited to once every five years and only if dentally appropriate.
- Reline of complete or partial dentures is allowed once every two years.
- Laboratory relines are not payable within five months after placement of an immediate denture.
- Tissue conditioning is allowed once per denture unit in conjunction with immediate dentures.
- One tissue conditioning is allowed prior to new prosthetic placement.
- Cast partial dentures will not be approved if stainless steel crowns are used as abutments.
- Cast partial dentures must have one or more anterior teeth missing or four or more missing posterior teeth per arch with resulting space equivalent to that loss demonstrating inability to masticate. Third molars are not a consideration when counting missing teeth.
- Rebase should only be done if a reline will not adequately solve the problem. Rebase is limited to once every three years.
- Laboratory Denture Reline Procedures -- Limited to once every two years.
ORAL SURGERY
The extraction of teeth is a covered benefit.
ORTHODONTIA
Orthodontia services are limited to eligible clients for the ICD-9-CM diagnosis of cleft palate with cleft lip.
ANESTHESIA
- General anesthesia or IV sedation is to be used only for those clients with concurrent needs: age, physical, medical or mental status, or degree of difficulty of the procedure
- Oral pre-medication anesthesia for conscious sedation
- Limited to clients through 12 years of age
- Limited to four times per year
- Monitoring and nitrous oxide included in the fee
- Use of multiple agents is required to receive payment
OHP STANDARD BENEFITS – COVERED PROCEDURES
The intent of the OHP Standard Limited Emergency Dental benefit is to provide services requiring immediate treatment and is not intended to restore teeth.
Services are limited to treatment for conditions such as:
- Acute infection
- Acute abscesses
- Severe tooth pain
- Tooth re-implantation when clinically appropriate
- Extraction of teeth is limited only to those teeth that are symptomatic
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