(1) The maximum dental benefits paid will be 85% of the billed services received up to $350 paid per benefit year for each enrollee. For example, $412 in services received would result in $350 paid.

(a) Providers may not balance bill the enrollee, parent, or guardian for the remaining 15% of the billed charges.

(b) Providers may bill the enrollee, parent, or guardian for services received in excess of $412 per benefit year.

(2) Providers must bill for services using the procedure codes and modifiers set forth, and according to the definitions contained in the American Dental Association Manual of Current Dental Terminology Third Edition (CDT-3).

(3) The following procedures are not a benefit of the HMK coverage group Dental Program:

(a) D5900 through D5999 maxillofacial prosthetics;

(b) D6000 through D6199 implant services;

(c) D7610 through D7780 treatment of fractures;

(d) D7940 through D7999 other repair procedures; and

(e) D8000 through D8999 orthodontics.

(4) Providers must comply with all applicable state and federal statutes, rules and regulations, including the United States Code governing the HMK Plan and all applicable Montana statutes and rules governing licensure and certification.

(5) Enrollees with significant dental needs beyond those covered in the basic dental plan may, with prior authorization, receive additional services through the HMK coverage group Extended Dental Plan (EDP). The EDP program is dependent on legislative appropriation for the program.

(a) A HMK coverage group enrollee determined eligible for extended dental benefits may receive additional services in the benefit year. The maximum EDP payment to all dental providers for an enrollee's additional dental services is $1000 per benefit year.

(b) The type of services covered by the EDP are the same type of services covered under the basic dental plan.

(c) The maximum basic and EDP payments combined is $1350 ($350 basic plan and $1000 EDP) for a benefit year.

(6) Providers must also comply with the requirements of ARM Title 37, chapter 85, subchapters 4 and 5 to the extent those provisions are not inconsistent with this subchapter.

(7) For purposes of applying the provisions of any Medicaid rule as required by this subchapter, references in the Medicaid rule to "Medicaid" or the "Montana Medicaid program" or similar references shall be deemed to apply to the HMK coverage group or the HMK Plus coverage group as the context permits.