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:

• Additional Oral Evaluation (D0120 or D0150)
  - One additional of either code per calendar year
• Molar root canal (D3330)
  - One per tooth per lifetime
• Root canal re-treatment (D3346, D3347, D3348)
  - One re-treat per tooth per lifetime. Covered only if 24 months after original root canal.
• Full mouth series (x-ray) (D0210)
  - Once per five years
• Crown (D2740 or D2750)
  - Two per calendar year
  - Porcelain/ceramic or Porcelain fused to high noble metal
• Re-cement or crown repair (D2920 or D2980)
  - One of either code per year
• 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
• Tissue conditioning (D5850 and D5851)
  - One treatment per arch per calendar 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

651-768-1415
1-855-648-1415
TTY 711
NO ENGLISH 1-800-553-9536