Form CMS-10291 Children's Dental Benefits Survey

Children's Dental Benefits Survey
State: _______________________________________	Name of Program(s): _____________________________________
Please complete separate surveys for Medicaid and CHIP if children's dental benefits differ between the two programs.
This survey describes children's pediatric dental benefits covered under (check appropriate box):
o Medicaid	o Separate CHIP program that uses a Medicaid benefits package
o Title XXI funded Medicaid expansion	o Separate CHIP program that has a unique benefits package
Children's Dental Services	Is the service covered? (mark response with an 'X')			Frequency (specify periodicity)	List any service-specific limitations
	Yes	Only with prior authorization	No		(eg. age limits, tooth-specific limits, or a cost or dollar threshold above which prior authorization is required)
I. Preventive Services
A. Cleanings
B. Fluoride treatments (including fluoride varnishes)
C. Sealants (list any tooth-specific limits)
D. Space maintainers
II. Diagnostic Services
A. Dental examinations
Recommended age of first visit? ______________
B. X-Rays
i. Bitewing
ii. Full Mouth
iii. Panoramic
Children's Dental Services	Is the service covered? (mark response with an 'X')			List any service-specific limitations
	Yes	Only with prior authorization	No	(eg. age limits, tooth-specific limits, or a cost or dollar threshold above which prior authorization is required)
III. Treatment Services
A. Fillings
i. Silver amalgam
ii. Tooth colored composite
B. Crowns/tooth caps
i. Stainless steel crowns
ii. Metal (only) crowns
iii. Metal/porcelain crowns
i. Porcelain (only) crowns
C. Root Canals (endodontics)
i. Root canals on baby teeth (pulpotomies)
ii. Root canals on permanent teeth
D. Gum (periodontal) therapy
E. Dentures
i. Partial dentures
ii. Complete dentures
Children's Dental Services	Is the service covered? (mark response with an 'X')			List any service-specific limitations
	Yes	Only with prior authorization	No	(eg. age limits, tooth-specific limits, or a cost or dollar threshold above which prior authorization is required)
iii. Bridges
F. Orthodontics*
i. Retainers (orthodontic)
ii. Braces
Criteria for braces coverage:
I. Oral surgery
i. Simple extractions
ii. Surgical extractions
iii. Care of abscesses
iv. Cleft palate treatment
v. Cancer treatment
vi. Treatment of fractures
vii. Biopsies
Children's Dental Services	Is the service covered? (mark response with an 'X')			List any service-specific limitations
	Yes	Only with prior authorization	No	(eg. age limits, tooth-specific limits, or a threshold above which prior authorization is required)
J. Treatment of jaw joint problems (TMJ)
Criteria for coverage:
K. Emergency room services provided by a dentist
Criteria for coverage:
L. Inpatient hospital services
Criteria for coverage:
M. Anesthesia
i. General anesthesia
Criteria for coverage:
ii. Intravenous conscious sedation
Criteria for coverage:
Children's Dental Services	Is the service covered? (mark response with an 'X')			List any service-specific limitations
	Yes	Only with prior authorization	No	(eg. age limits, tooth-specific limits, or a threshold above which prior authorization is required)
iii. Non-intravenous conscious sedation
Criteria for coverage:
iv. Analgesia (nitrous oxide)
Criteria for coverage:
If applicable, please provide the amount of the annual cost or funding level above which prior authorization is required________
* When this information is posted on the Insure Kids Now website, we recommend that there be a special note for orthodontic services explaining that parents and caretakers should work with their child's orthodontist to ensure that the treatment and payment terms and conditions are clear at the outset of treatment (for example, what happens in the case of a child who becomes ineligible for Medicaid or CHIP while he or she is undergoing orthodontic treatment?). According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1065. The time required to complete this information collection along with the Description of Dental Benefits (Attachment A) is estimated to average 30 hours annually per response, including the time to review instructions, search existing data resources, gather the data needed, and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to CMS, 7500 Security Boulevard, Attn” PRA Reports Clearance Officer, Mails Stop C4-26-05, Baltimore, Maryland 21244-1850.