Cal. Code Regs. tit. 10, § 2239.10
(b) For purposes of this Section only, the following definitions apply:
(c) Summary of Dental Benefits and Coverage Disclosure Matrix Usage Requirements
(d) Requirements for providing the Summary of Dental Benefits and Coverage Disclosure Matrix to Prospective or Current Enrollees for Individual and Group Coverage.
(1) Individual Coverage. An insurer subject to this Section shall provide a SDBC for each health insurance policy that provides coverage for dental benefits offered in the individual market in the following manner:
(A) For prospective individual enrollment.
(B) For individual applications for dental coverage.
(E) Method of Delivery. An insurer shall provide the SDBC in one or more of the following ways:
3. By placing it on the insurer's website. If provided on the insurer's website, the insurer shall:
(2) Group Contracts. An insurer subject to this Section offering group coverage shall provide a SDBC for each policy that provides coverage for dental benefits it offers in the group market in the following manner:
(D) Method of Delivery. An insurer shall provide the SDBC in one or more of the following ways.
3. By placing it on the insurer's website. If provided on the insurer's website, the insurer shall:
(3) Group Policyholder Obligations.
(B) Upon application for dental coverage. The group policyholder shall provide the applicable SDBC to each person eligible to be insured under the group policy as part of any written application materials that are distributed for enrollment at the time the application materials are distributed.
(E) Method of Delivery. A group policyholder shall provide the SDBC in one or more of the following ways:
(h) The SDBC provided pursuant to this Section shall constitute a vital document for the purposes of section 10133.8 of the Insurance Code.
(i) Summary of Dental Benefits and Coverage Disclosure Matrix (SDBC)
Summary of Dental Benefits and Coverage Disclosure Matrix (SDBC)
Part I: GENERAL INFORMATION
Insurer Name:
Plan Name:
Policy Type: [e.g., PPO, EPO, etc.]
Insurer Phone #: [for consumers]
Effective Date: [see (j)(2)(C) of this Section]
Insurer Website:
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND WHAT YOU WILL PAY FOR COVERED SERVICES. THIS IS A SUMMARY ONLY AND DOES NOT INCLUDE THE PREMIUM COSTS OF THIS DENTAL BENEFITS PACKAGE. PLEASE CONSULT YOUR EVIDENCE OF COVERAGE AND DENTAL CONTRACT FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. FOR MORE INFORMATION ABOUT YOUR COVERAGE, VISIT THE INSURER WEBSITE AT [insert insurer website] OR CALL [insert insurer phone number].
THIS MATRIX IS NOT A GUARANTEE OF EXPENSES OR PAYMENT.
Part II: DEDUCTIBLES
Deductible
[In-Network] or [All Providers]
[Out-of-Network]
Dental
[indicate whether “per individual or “per family” and enter $ amount]
[indicate whether “per individual or “per family” and enter $ amount]
Orthodontia
[indicate whether “per individual or “per family” and enter $ amount]
[indicate whether “per individual or “per family” and enter $ amount]
• [The deductible applies to all services / all services except [list exceptions here] / the following services [list services here].] OR [There is no deductible.]
• A deductible is the amount you are required to pay for covered dental services each policy year before the insurer begins to pay for the cost of covered dental treatment.
• In-network services are dental care services provided by dentists or other licensed dental care providers that contract with your insurer for alternative rates of payment for dental services.
• Out-of-network services are dental care services provided by dentists or other licensed dental care providers that have not contracted with your insurer for alternative rates of payment.
Part III: MAXIMUMS POLICY WILL PAY
Maximums
In-Network
Out-of-Network
Annual Maximum
[enter $ amount]
[Enter & or indicate [Yes, the cost-sharing will be higher. Contact your Plan.], [No], or [Not applicable]]
Lifetime or Annual Maximum for Orthodontia
[indicate whether lifetime or annual and enter $ amount]
[indicate whether lifetime or annual and enter $ amount]
• Annual maximum is the maximum dollar amount your policy will pay toward the cost of dental care within a specific period of time, usually a consecutive 12-month or calendar year period. Not all services accrue to the annual maximum.
• Lifetime maximum means the maximum dollar amount your policy providing dental benefits will pay for the life of the enrollee. Lifetime maximums usually apply to specific services, such as orthodontic treatment.
Part IV: WAITING PERIODS
Waiting Periods: A waiting period is the amount of time that must pass before you are eligible to receive benefits or services for all or certain dental treatments. [Describe waiting period or indicate there is no waiting period.]
Part V: WHAT YOU WILL PAY
All copayments and coinsurance costs shown in this chart apply after your deductible has been met, if a deductible applies. The Common Dental Procedures fit into one of the following applicable categories: Preventive & Diagnostic, Basic or Major. The Benefit Limitations and Exclusions column includes common limitations and exclusions only. For a full list, see the full disclosure document referenced in the Benefit Limitations and Exclusions column.
Common Dental Procedures
Category
In-Network
Out-of-Network
Benefit Limitations and Exclusions
Oral Exam
[Category]
[Enter % or $ amount]
[Enter % or $ amount]
[List as applicable]
Bitewing X-ray
[Category]
[Enter % or $ amount]
[Enter % or $ amount]
[List as applicable]
Cleaning
[Category]
[Enter % or $ amount]
[Enter % or $ amount]
[List as applicable]
Filling
[Category]
[Enter % or $ amount]
[Enter % or $ amount]
[List as applicable]
Extraction, Erupted Tooth or Exposed Root
[Category]
[Enter % or $ amount]
[Enter % or $ amount]
[List as applicable]
Root Canal
[Category]
[Enter % or $ amount]
[Enter % or $ amount]
[List as applicable]
Scaling and Root Planing
[Category]
[Enter % or $ amount]
[Enter % or $ amount]
[List as applicable]
Ceramic Crown
[Category]
[Enter % or $ amount]
[Enter % or $ amount]
[List as applicable]
Removable Partial Denture
[Category]
[Enter % or $ amount]
[Enter % or $ amount]
[List as applicable]
Extraction, Erupted Tooth with Bone Removal
[Category]
[Enter % or $ amount]
[Enter % or $ amount]
[List as applicable]
Orthodontia
Orthodontia
[Enter % or $ amount]
[Enter % or $ amount]
[List as applicable]
Part VI: COVERAGE EXAMPLES
THESE EXAMPLES DO NOT REPRESENT A COST ESTIMATOR OR GUARANTEE OF PAYMENT. The examples provided represent commonly used services in the categories of Diagnostic and Preventive, Basic and Major Services for illustrative purposes and to compare this product to other dental products you may be considering. Your actual costs will likely be different from those shown in the chart below depending on the actual care you receive, the prices your providers charge and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and the summary of excluded services under the plan.
Dana Has a Dental Appointment with a New Dentist
Sam Needs a Tooth Filled
Maria Needs a Crown
New patient exam, x-rays (FMX) and cleaning
Resin-based composite - one surface, posterior
Crown - porcelain/ceramic substrate
Dana's Visit
Dana's Cost
Sam's Visit
Sam's Cost
Maria's Visit
Maria's Cost
Total Cost of Care
In-network: $400 Out-of-network: $550
Total Cost of Care
In-network: $150 Out-of-network: $200
Total Cost of Care
In-network: $1,300 Out-of-network: $1,750
Deductible
In-network: [Enter $ amount]
Deductible
In-network: [Enter $ amount]
Deductible
In-network: [Enter $ amount]
Out-of-network: [Enter $ amount]
Out-of-network: [Enter $ amount]
Out-of-network: [Enter $ amount]
Annual Maximum (Plan Will Pay)
In-network: [Enter $ amount]
Annual Maximum (Plan Will Pay)
In-network: [Enter $ amount]
Annual Maximum (Plan Will Pay)
In-network: [Enter $ amount]
Out-of-network: [[Enter $ amount] or indicate [Yes, the cost-sharing will be higher. Contact your Plan.], [No], or [Not applicable]]
Out-of-network: [[Enter $ amount or indicate [Yes, the cost-sharing will be higher. Contact your Plan.], [No], or [Not applicable]]
Out-of-network: [[Enter $ amount or indicate [Yes, the cost-sharing will be higher. Contact your Plan.], [No], or [Not applicable]]
Patient Cost (copayment or coinsurance)
In-network: [Enter % or $ amount]
Patient Cost (copayment or coinsurance)
In-network: [Enter % or $ amount]
Patient Cost (copayment or coinsurance)
In-network: [Enter % or $ amount]
Out-of-network: [Enter % or $ amount]
Out-of-network: [Enter % or $ amount]
Out-of-network: [Enter % or $ amount]
Dana's Visit
Dana's Cost
Sam's Visit
Sam's Cost
Maria's Visit
Maria's Cost
In this example, Dana would pay (includes copays/
In-network: [Enter $ amount]
In this example, Sam would pay (includes copays/
In-network [Enter $ amount]
In this example, Maria would pay (includes copays/
In-network: [Enter $ amount]
coinsurance and deductible, if applicable):
Out-of-network: [Enter $ amount]
coinsurance and deductible, if applicable):
Out-of-network: [Enter $ amount]
coinsurance and deductible, if applicable):
Out-of-network: [Enter $ amount]
Summary of what is not covered or subject to a limitation:
[List as applicable]
Summary of what is not covered or subject to a limitation:
[List as applicable]
Summary of what is not covered or subject to a limitation:
[List as applicable]
(j) Instructions for Completion of Summary of Dental Benefits and Coverage Disclosure Matrix
(1) Formatting and Use
(2) Part I: General Information
(3) Part II: Deductible
(4) Part III: Maximums
(5) Part IV: Waiting Periods
(6) Part V: What You Will Pay
(A) Dental procedures listed below, and in the first column of the “WHAT YOU WILL PAY” table, may not be altered in any way. For purposes of the SDBC, the following procedures are defined as follows:
(E) Benefit Limitations and Exclusions Column: In this column, list the following, if applicable:
(7) Part VI: Coverage Examples
Note: Authority cited: Section 10603.04, Insurance Code. Reference: Sections 10133.8, 10290 and 10603.04, Insurance Code.
1. New article 5.6 (section 2239.10) and section filed 1-28-2021 as an emergency; operative 1-28-2021 (Register 2021, No. 5). Pursuant to Insurance Code section 10603.04(f), this action is a deemed emergency and exempt from OAL review. Expiration date of emergency extended 60 days (Executive Order N-40-20) plus an additional 60 days (Executive Order N-71-20). A Certificate of Compliance must be transmitted to OAL by 9-27-2021 or emergency language will be repealed by operation of law on the following day.
2. New article 5.6 (section 2239.10) and section refiled 9-27-2021 as an emergency; operative 9-27-2021 (Register 2021, No. 40). Pursuant to Insurance Code section 10603.04(f), this action is a deemed emergency and exempt from OAL review. A Certificate of Compliance must be transmitted to OAL by 12-27-2021 or the emergency language will be repealed by operation of law on the following day.
3. New article 5.6 (section 2239.10) and section refiled 12-20-2021 as an emergency; operative 12-28-2021 pursuant to Government Code section 11343.4(b)(2) (Register 2021, No. 52). Pursuant to Insurance Code section 10603.04(f), this action is a deemed emergency and exempt from OAL review. A Certificate of Compliance must be transmitted to OAL by 3-28-2022 or emergency language will be repealed by operation of law on the following day.
4. Certificate of Compliance as to 12-20-2021 order, including amendment of section, transmitted to OAL 3-24-2022 and filed 5-5-2022; amendments operative 7-1-2022 pursuant to Government Code section 11343.4(a)(3) (Register 2022, No. 18).