California Code of Regulations
Title 10 - Investment
Chapter 5 - Insurance Commissioner
Subchapter 2 - Policy Forms and Other Documents
Article 5.6 - Disclosure Forms in Health Insurance
Section 2239.10 - Summary of Dental Benefits and Coverage Disclosure Matrix

Universal Citation: 10 CA Code of Regs 2239.10

Current through Register 2024 Notice Reg. No. 38, September 20, 2024

(a) Applicability: This Section shall apply to insurers that issue, sell, renew, or offer a policy of health insurance as defined in section 106 of the Insurance Code that provides coverage for dental benefits in this state.

(b) For purposes of this Section only, the following definitions apply:

(1) "Group Policyholder" means a group, association, or employer that contracts with an insurer to provide coverage for dental benefits for members or employees.

(2) "Insurer" means an entity that provides health insurance as defined in section 106 of the Insurance Code, including its agents and representatives, and that issues, sells, renews, or offers a policy that provides coverage for dental benefits.

(3) "Policy year" means a calendar year or other period of time during which a policy that provides coverage for dental benefits is in effect, as designated in the contract between the individual or group and the insurer.

(c) Summary of Dental Benefits and Coverage Disclosure Matrix Usage Requirements

(1) An insurer subject to this Section shall use the Summary of Dental Benefits and Coverage Disclosure Matrix (SDBC), in the form set forth in subdivision (i) of this Section, for each plan that provides coverage for dental benefits it issues, sells, renews, or offers. Copies of the SDBC can also be found on the Department of Insurance website, www.insurance.ca.gov. search "SB1008 Dental Matrix."

(2) An insurer shall use only a SDBC that reflects benefits, including cost-sharing, exclusion, and limitation provisions, of a policy that is authorized for use pursuant to section 10290 of the Insurance Code.

(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.
1. When presenting any policy for examination or sale to a prospective individual insured, the insurer shall provide the individual an applicable SDBC for each policy that provides coverage for dental benefits for which the individual is eligible at the same time it provides other disclosure materials, including the evidence of coverage.

2. When requested, an insurer shall provide a SDBC for each applicable policy that provides coverage for dental benefits for which the prospective individual insured is eligible, including any other disclosure materials the insurer is required to provide, within 7 business days following the request.

(B) For individual applications for dental coverage.
1. Within 7 business days following receipt of the application for coverage, the insurer shall provide the individual prospective insured with the applicable SDBC and any other disclosure materials the insurer is required to provide.

2. If the insurer provided an applicable SDBC to the prospective individual insured before the individual applied for coverage, the insurer shall be in compliance with (d)(1)(B)(1) if the applicable SDBC the insurer provided to the individual does not differ from the applicable SDBC in effect at the time of application. If the applicable SDBC in effect at the time of application differs from the SDBC the insurer provided to the individual, the insurer must provide the current applicable SDBC to the individual within 7 business days following receipt of the application but no later than the first day of coverage.

(C) Changes to the SDBC. If the applicable SDBC in effect between the date of application and the first day of coverage differs from the SDBC the insurer provided to the individual prospective insured pursuant to (d)(1)(B)(1), the insurer shall provide the current applicable SDBC to the individual no later than the first day of coverage.

(D) Renewal or reenrollment of dental coverage. The SDBC shall be provided no later than the date on which the coverage application and other disclosure materials are distributed. If renewal occurs automatically, the SDBC shall be provided no later than 30 days before the beginning of the policy year.

(E) Method of Delivery. An insurer shall provide the SDBC in one or more of the following ways:
1. In paper form, free of charge, and delivered to the individual's mailing address.

2. Electronically by email, if the individual has agreed to conduct transactions by electronic means pursuant to section 1633.5 of the Civil Code. The insurer shall notify the insured a paper copy is available free of charge and inform the enrollee how to contact the insurer for a paper copy or with questions.

3. By placing it on the insurer's website. If provided on the insurer's website, the insurer shall:
a. Place the SDBC in a location on the insurer's public website that is prominent and easy to access;

b. Ensure the SDBC allows for electronic retention, such as saving and printing;

c. Ensure the SDBC is accessible to individuals living with disabilities in accordance with applicable federal and state law; and

d. Notify the insured that a paper copy is available free of charge and inform the enrollee how to contact the insurer for a paper copy or with any questions.

(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:
(A) Delivery of SBDC. When a group contracts for coverage, the insurer shall provide the applicable SDBCs to the group upon delivery of the policy. The SDBC shall be provided at the same time the insurer provides other disclosure materials, including the applicable evidence of coverage.

(B) Changes to the SDBC. If the insurer's applicable SDBC in effect between the date the group signs the contract for coverage and the group's first day of coverage differs from the SDBC the insurer provided to the group pursuant to (d)(2)(A), the insurer shall provide the updated applicable SDBC to the group no later than the first day of coverage.

(C) Renewal or reenrollment of dental coverage. The insurer shall provide the SDBC no later than the date on which other disclosure materials including the evidence of coverage are distributed. If renewal occurs automatically, the insurer shall provide the SDBC no later than 30 days before the first day of the policy year.

(D) Method of Delivery. An insurer shall provide the SDBC in one or more of the following ways.
1. In paper form free of charge and delivered to the group's mailing address.

2. Electronically by email, if the group policyholder has agreed to conduct transactions by electronic means pursuant to section 1633.5 of the Civil Code. The insurer shall notify the group policyholder a paper copy is available free of charge and inform the group policyholder how to contact the insurer for a paper copy or with any questions.

3. By placing it on the insurer's website. If provided on the insurer's website, the insurer shall:
a. Place the SDBC in a location on the insurer's public website that is prominent and easy to access;

b. Ensure the SDBC allows for electronic retention, such as saving and printing;

c. Ensure the SDBC is accessible to individuals living with disabilities in accordance with state and federal requirements; and

d. Notify the group policyholder a paper copy is available free of charge and inform the group policyholder how to contact the insurer for a paper copy or with any questions.

(3) Group Policyholder Obligations.
(A) Prior to enrollment. When offering coverage to any person eligible to be insured under the group policy, the group policyholder shall provide an applicable SDBC for each policy that provides coverage for dental benefits it is offering to each eligible person at the same time the group policyholder provides other disclosure materials.

(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.
1. The SDBC and any other required disclosure materials shall be provided to the applicant by the group policyholder within 7 business days following receipt of the application for coverage.

2. If the group policyholder provided an applicable SDBC to the applicant prior to their applying for coverage, the group policyholder shall be in compliance with (d)(3)(B)(1) if the SDBC the group policyholder provided to the applicant does not differ from the applicable SDBC in effect at the time of application. If the SDBC the group policyholder provided to the applicant differs from the applicable SDBC in effect at the time of application, the group policyholder shall provide the current SDBC to the applicant within 7 business days after receipt of the application but no later than the first day of coverage.

(C) Changes to the SDBC. If the applicable SDBC in effect between the date of application and the first day of coverage differs from the SDBC the group policyholder provided to the applicant pursuant to (d)(3)(B)(1), the group policyholder shall provide the current applicable SDBC to the applicant no later than the first day of coverage.

(D) Renewal or reenrollment of dental coverage. The group policyholder shall provide the SDBC no later than the date on which the coverage application and other disclosure materials are distributed. If renewal occurs automatically, the group policyholder shall provide the SDBC no later than 30 days prior to the first day of the policy year.

(E) Method of Delivery. A group policyholder shall provide the SDBC in one or more of the following ways:
1. In paper form free of charge, and delivered to the individual's mailing address.

2. Electronically by email. The group policyholder shall notify the certificate holder that a paper copy is available free of charge and provide information on how to contact the group policyholder for a paper copy or with any questions.

3. Electronically by directing the certificate holder to the insurer's website for a copy of the SDBC. The group policyholder shall notify the certificate holder that a paper copy is available free of charge and provide information on how to contact the group policyholder for a paper copy or with any questions.

(e) Special Enrollment. An insurer shall provide the SDBC to an insured or prospective insured qualifying for coverage under a special enrollment period at the same time it provides other disclosure information, including the evidence of coverage.

(f) When requested by an insured, regardless of whether in individual or group coverage, the insurer shall provide the applicable SDBC within 7 business days of the request by the methods described in (d)(1)(E).

(g) The insurer shall require that all group policyholders comply with the requirements of this Section.

(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

MaximumsIn-NetworkOut-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 ProceduresCategoryIn-NetworkOut-of-NetworkBenefit 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]
OrthodontiaOrthodontia[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 DentistSam Needs a Tooth FilledMaria Needs a Crown
New patient exam, x-rays (FMX) and cleaningResin-based composite - one surface, posteriorCrown - porcelain/ceramic substrate
Dana's VisitDana's CostSam's VisitSam's CostMaria's VisitMaria's Cost
Total Cost of CareIn-network: $400 Out-of-network: $550Total Cost of CareIn-network: $150 Out-of-network: $200Total Cost of CareIn-network: $1,300 Out-of-network: $1,750
DeductibleIn-network: [Enter $ amount]DeductibleIn-network: [Enter $ amount]DeductibleIn-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 VisitDana's CostSam's VisitSam's CostMaria's VisitMaria'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
(A) The Summary of Dental Benefits and Coverage Disclosure Matrix (SDBC) must be a stand-alone document that is not incorporated into any other document.

(B) Do not alter or remove existing formatting or language unless otherwise specified in or permitted by this instruction guide, or required by law.

(C) Insurers shall use Arial 12-point font, with the exception of any addition made in accordance with paragraph (2)(E).

(D) Prior to distribution of the matrix, remove text that is bracketed.

(2) Part I: General Information
(A) Insert insurer and policy specific information in this section and replace bracketed text, as directed.

(B) "Plan Name" may be the Insurer's plan identifier.

(C) Effective Date: Use the following format to report the applicable beginning and end dates for the policy year: XX/XX/XXXX - XX/XX/XXXX. If the end date for the coverage period is not known, insert: Beginning on or after XX/XX/XXXX.

(D) The phone number listed in this Part shall be the insurer's customer service phone number for consumers.

(E) Insurers may add logo or co-branding text or symbols. Any addition must appear on the first page above the title of the document, "Summary of Dental Benefits and Coverage Disclosure Matrix (SDBC)."

(3) Part II: Deductible
(A) Report the in-network and out-of-network deductibles for both Dental and Orthodontia here. If there is no deductible, state "None" in the table. If there are different deductibles for "Individual" and "Family," include both. For EPO policies, state "Not Covered" in the out-of-network column. For policies that do not distinguish between in-network and out-of-network providers, or that include a combined deductible for both in-network and out-of-network, replace "In-Network" with "All Providers" and remove the Out-of-Network column.

(B) In the first bullet below the Deductibles table, use the template language to report the services to which the deductible applies. For brevity, this may be a summary statement, noting exceptions.

(4) Part III: Maximums
(A) Report the applicable maximums, as directed in the Maximum Table. If there are no maximums, state "None" in the table.

(B) For "Out-of-Network," select one of the four choices:
(1) [Enter $ amount] or

(2) [Yes. the cost-sharing will be higher. Contact your Plan];

(3) [No]; or

(4) [Not applicable]. If the choice selected is "Yes" include the additional text in the SDBC.

(C) For EPO policies, state "Not Covered" in the out-of-network column. For policies that do not distinguish between in-network and out-of-network providers, or that include a combined maximum for both in-network and out-of-network, replace "In-Network" with "All Providers" and remove the Out-of-Network column.

(5) Part IV: Waiting Periods
(A) Report all waiting periods applicable to the policy here, including the length of the waiting period(s) and the service(s) to which they apply. If there are no waiting periods, include a statement to that effect.

(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:
1. Oral Exam: comprehensive oral evaluation - new or established patient

2. Bitewing X-ray: single radiographic image

3. Cleaning: prophylaxis - adult

4. Filling: resin based composite - one surface, anterior

5. Extraction, Erupted Tooth or Exposed Root: extraction, erupted tooth or exposed root (elevation and/or forceps removal)

6. Root Canal: endodontic therapy, molar tooth (excluding final restoration)

7. Scaling and Root Planing: periodontal scaling and root planing - four or more teeth per quadrant

8. Ceramic Crown: porcelain/ceramic

9. Removable Partial Denture: maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests, and teeth)

10. Extraction, Erupted Tooth with Bone Removal: extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of the mucoperiosteal flap if indicated

(B) Include in the Category column one of the following descriptions: Preventive & Diagnostic; Basic; or Major as applicable to each service.

(C) In the In-Network and Out-of-Network columns include the copayment or coinsurance applicable for each service or, if there is no copayment or coinsurance, include a clear description of the amount the member will pay for each service. For Orthodontia, if a single copayment or coinsurance does not apply to a course of treatment, please include the full range of costs with a statement that the cost is "per service." If the plan has a deductible and the deductible does not apply to a particular benefit, state "deductible does not apply" after the copayment or coinsurance for that service (e.g., "$50, deductible does not apply"). For EPO policies, state "Not Covered" in the out-of-network column. For policies that do not distinguish between in-network and out-of-network providers, replace "In-Network" with "All Providers" and remove the Out-of-Network column.

(D) For any service in the SDBC not covered by the product, state "Not Covered" in the In-Network and/or Out-of-Network columns, as applicable.

(E) Benefit Limitations and Exclusions Column: In this column, list the following, if applicable:
1. Limits on the frequency of the service (e.g. one per year).

2. Waiting periods.

3. If cost sharing is different when the service is performed by a specialist (as compared to a general dentist), make a note and include that amount or percentage.

4. If the service will be covered only if performed by a general dentist.

5. A cross reference to the disclosure document(s) where the full limitations and exclusions for the policy can be found.

(7) Part VI: Coverage Examples
(A) The "Total Cost of Care" amount populated in the table is for illustrative purposes and may not be altered.

(B) Fill in the deductible, annual maximum, copayment/coinsurance and cost for service using information applicable to the specific policy referenced in (j)(2), above.

(C) Report the information for in-network and out-of-network where the form indicates. Except as directed in (E), below, when services are not covered out of network, report "Not Covered" next to "Out-of-network."

(D) If the deductible does not apply to the service(s), report "Not Applicable" in the associated box.

(E) The "In this example, [enrollee] would pay" row shall include the hypothetical cost share the enrollee would be responsible for, utilizing the provided cost of care. Include the deductible, if applicable, in the calculation. If the cost of the example itself would exceed the annual limit on its own, that should be reflected in the reported example cost. If the services are not covered out-of-network, this row shall reflect the full cost of the service next to "Out-of-network."

(F) The "What is not covered or subject to a limitation" row shall include all items listed in these instructions under (j)(6)(E), numbers 1-4, above.

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).

Note: Authority cited: Section 10603.04, Insurance Code. Reference: Sections 10133.8, 10290 and 10603.04, Insurance Code.

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