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Dental Benefits for CHIP

The following benefits are for children who have CHIP. Benefits with a $0 co-pay: Routine exams, cleanings (2 per year), topical fluoride, x-rays Benefits with a co-pay*: Basic Services: CHIP A - $0 CHIP B - 5% of approved amount CHIP C - 20% of approved amount after deductible Basic services include fillings, extractions, oral surgery, etc. Major Services and Specialist Services: CHIP A - 5% of approved amount CHIP B - 5% of approved amount CHIP C - 50% of approved amount after deductible Major services include crowns, bridges, dentures, etc. Specialists include endodontists, periodontists, oral surgeons, prosthodontists, etc. . Reminders: If you cannot pay your co-pay, please help the dentist by canceling your appointment the day before. You must go to a dentist who is enrolled in your dental plan's network, either Premier Access or DentaQuest. Make sure you ask which dental plan your dentist accepts. Remember to take your CHIP dental ID card to each appointment. *American Indians/Alaska Natives do not pay co-pays.

Finding a Medicaid Dentist

If you already have a dentist who takes your dental benefit and sees you regularly, stay with that dentist. He or she knows you and has a history of giving you care. Your dentist must be a Medicaid provider. Please take your current Medicaid card to all appointments.

If you need to find a dentist:

Call the Medicaid Hotline: (801) 538-6155 or 1-800-662-9651 Call a clinic in your area: Greenwood Dental Clinic

7495 South State Street, Midvale (801) 213-9530

Mountain Ridge Dental Clinic

1256 South State Street, Suite 103, Orem (801) 224-7182 (Accepts Medicaid, CHIP, PCN & offers a 10% discount for clients without insurance)

Salt Lake Donated Dental Services

Sorensen Center 1383 South 990 West, Salt Lake City (801) 983-0345 (Accepts Medicaid, PCN, CHIP, low income & homeless clients)

288 N 1460 W SLC, UT 84114 1-800-662-9651

Tri County Health Department Dental Clinic

133 South 500 East, Vernal (435) 247-1192

February 2011

Dental Benefits Summary for Medicaid Clients

Medicaid offers dental benefits to children, until age 21 and pregnant women: You may have the following care at no charge to you:

Family Dental Plan

accepts MEDICAID, CHIP and PCN

FDP will still provide dental services for those who no longer have dental coverage through Medicaid. The services will be within the Medicaid scope of service and the patient must pay for the services according to the Medicaid reimbursement rates. Payment must be made at the time of service by cash or check with the proper identification.

Ogden Family Dental Plan 950 E 25th Street, Suite A Ogden, Utah 84401 (801) 395-7090 Provo Family Dental Plan 150 East Center Street, Suite 1100 Provo, Utah 84606 (801) 371-1024 Salt Lake City Family Dental Plan

Dental Benefit Summary for Primary Care Network

The following benefits are available for adults who are eligible for PCN. You may have the following care with a 10% per procedure copayment:

Check-ups, including x-rays and a cleaning every six months Resin (tooth colored fillings) for front teeth and some limited small fillings on back teeth Silver amalgam fillings for back teeth. Root canal treatment for certain teeth** Pulpotomies for infected baby teeth Extraction (pulling) of teeth Dentures, partial dentures** Space maintainers for children with missing teeth Some orthodontic care for children** Some specialty care or surgical centers for care under general anesthesia** Emergency exams for problems such as pain

Check-ups with x-rays and cleaning every six months Resin (tooth-colored) fillings for front teeth Silver amalgam fillings for back teeth Extraction (pulling) of teeth Emergency examination for treatment of problems such as toothache

168 North 1950 West, Suite 202 801-715-3400

St. George Family Dental Plan 321 North Mall Drive, Suite M101 St. George, Utah 84790 (435) 652-3806

Ask your provider for an estimated cost for each visit. Expect that the cost will be typically between $5 and $15 per visit. The cost will depend on the type and amount of work that you need. If you are on PCN, you must go to a dentist who is a Medicaid provider. Please take your current eligibility card to each dental visit to show you have benefits.

**Some services have special rules, limits or need prior approval. For more details, talk to your dentist.

If you are pregnant, getting your teeth cleaned in the 22nd to 26th week of pregnancy, can help you have a full term pregnancy.

Utah Navajo Health System, Inc.

(Accepts Medicaid, CHIP and PCN) P.O. Box 130, Montezuma Creek

(435) 651-3892

Does your child need fluoride drops or pills? Ask your child's medical or dental provider.

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