UCare's MSHO Dental Options

Dental benefits for members of UCare's Minnesota Senior Health Options (MSHO) (HMO D-SNP) plan.

<In addition to Medicare- and Medical Assistance-covered dental benefits, UCare's MSHO members have additional dental coverage for preventive and restorative dental services. Members must receive these services from a network dentist.

Below is a list of preventive and restorative codes that may be accessed:

• Scaling and root planing (D4341 and D4342)
  - Once every two years and only in an office setting. The member must have pocket depths of 4 mm or greater and documented bone loss visible on x-rays.
• Additional dental exam (D0120)
  - One additional per calendar year
• Molar root canal (D3330)
  - One per tooth per lifetime
• Root canal re-treatment (D3346, D3347, D3348)
  - Rule: One re-treat per tooth per lifetime. Covered only if billed 24 months after original root canal.
• Full mouth series (x-ray) (D0210)
  - Rule: Once per five years
• PFM crown (D2750 , D6245, D6740)
  - Two per calendar year
  - Porcelain-Fused-to-Metal
• Comprehensive oral evaluation (D0150)
  - One per year
• Panoramic film (D0330)
  - One additional per year
• Topical fluoride varnish (D1206)
  - For moderate to high caries risk members.
  -Second varnish per year
• Gross removal of plaque and calculus (D4355)
  - Additional one per year

Members will be informed of the portion of the cost they will need to pay for non-covered services. Certain limitations apply.>

Contact information

Dental Care Coordination Team
651-768-1415
1-855-648-1415
TTY 711
NO ENGLISH 1-800-553-9536

County Staff
Call Delta Dental
Government Programs Access Unity
651-994-5198
1-866-303-8138>