Galley § 2239.
10
<T10AH5.6>
Article 5.6. Disclosure Forms in Health
Insurance
<T10S2239.10>
§ 2239.10. Summary of Dental Benefits and Coverage
Disclosure Matrix.
(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 representa-
tives, and that issues, sells, renews, or offers a policy that provides cover-
age 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 insur-
er.
(c) Summary of Dental Benefits and Disclosure Matrix Usage Re-
quirements
(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.
(2) An insurer shall use only a SDBC that reflects benefits, including
cost−sharing, exclusion, and limitation provisions, of a policy that is au-
thorized 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 In-
dividual and Group Coverage.
(1) Individual Coverage. An insurer subject to this Section shall pro-
vide 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 disclo-
sure materials, including the evidence of coverage.
2. When requested, an insurer shall provide a SDBC for each applica-
ble 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 fol-
lowing the request.
(B) For individual applications for dental coverage.
1. Within 7 business days following receipt of the application for cov-
erage, the insurer shall provide the individual prospective insured with
the applicable SDBC and any other disclosure materials the insurer is re-
quired to provide.
2. If the insurer provided an applicable SDBC to the prospective indi-
vidual insured before the individual applied for coverage, the insurer
shall be in compliance with (d)(1)(B)(i) if the applicable SDBC the in-
surer provided to the individual does not differ from the applicable SD-
BC 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
Page 1
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 SD-
BC 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 automatical-
ly, the SDBC shall be provided no later than 30 days before the begin-
ning 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 mail-
ing 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. 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 in-
surer shall provide the applicable SDBCs to the group upon delivery of
the policy. The SDBC shall be provided at the same time the insurer pro-
vides 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 mate-
rials including the evidence of coverage are distributed. If renewal oc-
curs 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. 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;
§ NIL Galley

c. Ensure the SDBC is accessible to individuals living with disabilities holder shall provide the SDBC no later than the date on which the cover-
in accordance with state and federal requirements; and age application and other disclosure materials are distributed. If renewal
d. Notify the group policyholder a paper copy is available free of occurs automatically, the group policyholder shall provide the SDBC no
charge and inform the group policyholder how to contact the insurer for later than 30 days prior to the first day of the policy year.
a paper copy or with any questions. (E) Method of Delivery. A group policyholder shall provide the SD-
(3) Group Policyholder Obligations. BC in one or more of the following ways:
(A) Prior to enrollment. When offering coverage to any person eligi- 1. In paper form free of charge, and delivered to the individual’s mail-
ble to be insured under the group policy, the group policyholder shall ing address.
provide an applicable SDBC for each policy that provides coverage for 2. Electronically by email. The group policyholder shall notify the
dental benefits it is offering to each eligible person at the same time the certificate holder that a paper copy is available free of charge and pro-
group policyholder provides other disclosure materials. vide information on how to contact the group policyholder for a paper
(B) Upon application for dental coverage. The group policyholder copy or with any questions.
shall provide the applicable SDBC to each person eligible to be insured 3. Electronically by directing the certificate holder to the insurer’s
under the group policy as part of any written application materials that website for a copy of the SDBC. The group policyholder shall notify the
are distributed for enrollment at the time the application materials are certificate holder that a paper copy is available free of charge and pro-
distributed. vide information on how to contact the group policyholder for a paper
1. The SDBC and any other required disclosure materials shall be pro- copy or with any questions.
vided to the applicant by the group policyholder within 7 business days (e) Special Enrollment. An insurer shall provide the SDBC to an in-
following receipt of the application for coverage. sured or prospective insured qualifying for coverage under a special en-
2. If the group policyholder provided an applicable SDBC to the appli- rollment period at the same time it provides other disclosure informa-
cant prior to their applying for coverage, the group policyholder shall be tion, including the evidence of coverage.
in compliance with (d)(3)(B)(1) if the SDBC the group policyholder pro- (f) When requested by an insured, regardless of whether in individual
vided to the applicant does not differ from the applicable SDBC in effect or group coverage, the insurer shall provide the applicable SDBC within
at the time of application. If the SDBC the group policyholder provided 7 business days of the request by the methods described in (d)(1)(E).
to the applicant differs from the applicable SDBC in effect at the time of (g) The insurer shall require that all group policyholders comply with
application, the group policyholder shall provide the current SDBC to the requirements of this Section.
the applicant within 7 business days after receipt of the application but (h) The SDBC provided pursuant to this Section shall constitute a vital
no later than the first day of coverage. document for the purposes of section 10133.8 of the Insurance Code.
(C) Changes to the SDBC. If the applicable SDBC in effect between (i) Summary of Dental Benefits and Coverage Disclosure Matrix (SD-
the date of application and the first day of coverage differs from the SD- BC)
BC the group policyholder provided to the applicant pursuant to Copies of the SDBC can also be found on the Department of Insurance
(d)(3)(B)(1), the group policyholder shall provide the current applicable website, www.insurance.ca.gov, search “SB1008 Dental Matrix.”
SDBC to the applicant no later than the first day of coverage.
(D) Renewal or reenrollment of dental coverage. The group policy-
First Page
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 Instruction Guide Part I., C.] 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 [indicate whether “per individual or “per family”
$ amount] and enter $ amount]
S [The deductible applies to all services / all services except [list exceptions here] / the following services [list services here].] OR [There is no deductible.]
S 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.
S 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.
S 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.
Second Page
Part III: MAXIMUMS POLICY WILL PAY
Maximums In−Network Out−of−Network
Annual Maximum [enter $ amount] [Indicate [Yes, the cost−sharing will be higher. Contact
your Plan.], [No], or [Not applicable]]
Lifetime Maximum for [enter $ amount] [enter $ amount]
Orthodontia
S 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.
S 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 for all or certain dental treatments. [Describe waiting
period or indicate there is no waiting period.]
Part V: WHAT YOU WILL PAY

Page 2
 Galley § NIL

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 Category In−Network Out−of−Network Benefit Limitations and Exclusions
Procedures
Oral Exam [Category] [Enter % or $ [Enter % or $ amount] [List as applicable]
amount]
Bitewing X−ray [Category] [Enter % or $ [Enter % or $ amount] [List as applicable]
amount]
Cleaning [Category] [Enter % or $ [Enter % or $ amount] [List as applicable]
amount]
Third Page
Common Dental Category In−Network Out−of−Network Benefit Limitations and Exclusions
Procedures
Filling [Category] [Enter % or $ [Enter % or $ amount] [List as applicable]
amount]
Simple Extraction [Category] [Enter % or $ [Enter % or $ amount] [List as applicable]
amount]
Root Canal [Category] [Enter % or $ [Enter % or $ amount] [List as applicable]
amount]
Scaling and Root Planing [Category] [Enter % or $ [Enter % or $ amount] [List as applicable]
amount]
Ceramic Crown [Category] [Enter % or $ [Enter % or $ amount] [List as applicable]
amount]
Removable Partial [Category] [Enter % or $ [Enter % or $ amount] [List as applicable]
Denture amount]
Orthodontia Orthodontia [Enter % or $ [Enter % or $ amount] [List as applicable]
amount]
Fourth Page
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 policy to other dental policies you may be consid-
ering. 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 Sam Needs a Tooth Filled Maria Needs a Crown
New Dentist
New patient exam, x−rays (FMX) and Resin−based composite − one surface, Crown − porcelain/ceramic substrate
cleaning posterior
Dana’s Visit Dana’s Cost Sam’s Visit Sam’s Cost Maria’s Visit Maria’s Cost
Total Cost of Care In−network: $250 Total Cost of Care In−network: $150 Total Cost of Care In−network: $950
Out−of−network: Out−of−network: Out−of−network: $1,400
$450 $250
Deductible In−network: [Enter Deductible In−network: [Enter Deductible In−network: [Enter $ amount]
$ amount] $ amount]
Out−of−network: Out−of−network: Out−of−network:
[Enter $ amount] [Enter $ amount] [Enter $ amount]
Annual Maximum In−network: [Enter Annual Maximum In−network: [Enter Annual Maximum In−network: [Enter $ amount]
(Plan Will Pay) $ amount] (Plan Will Pay) $ amount] (Plan Will Pay)
Out−of−network: Out−of−network: Out−of−network:
Indicate [Yes, Indicate [Yes, Indicate [Yes,
the cost−sharing the cost−sharing the cost−sharing
will be higher. will be higher. will be higher.
Contact your Plan.], Contact your Plan.], Contact your Plan.],
[No], or [Not [No], or [Not [No], or [Not
applicable]] applicable] applicable]
Fifth Page
Dana’s Visit Dana’s Cost Sam’s Visit Sam’s Cost Maria’s Visit Maria’s Cost
Patient Cost In−network: Patient Cost In−network: [Enter Patient Cost In−network:
(copayment or [Enter % or (copayment or % or $ amount] (copayment or [Enter % or
coinsurance) $ amount] coinsurance) coinsurance) $ amount]

Out−of−network: Out−of−network: Out−of−network:

[Enter % or [Enter % or [Enter % or $ amount]
$ amount] $ amount]

In this example, In−network: [Enter In this example, In−network [Enter In this example, In−network: [Enter
Dana would pay $ amount] Sam would pay $ amount] Maria would pay $ amount]
(includes copays/ (includes copays/ (includes copays/
coinsurance and Out−of−network: coinsurance Out−of−network: coinsurance Out−of−network:
deductible, if [Enter $ amount] and deductible, [Enter $ amount] and deductible, [Enter $ amount]
applicable): if applicable): if applicable):

Page 3
§ NIL
Summary of what is [List as applicable] Summary of what
not covered or is not covered
subject to a limitation: or subject to a limitation:
(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 Ma-
trix (SDBC) must be a stand−alone document that is not incorporated in-
to any other document.
(B) Do not alter or remove existing formatting or language unless oth-
erwise specified in this instruction guide.
(C) Insurers shall use Arial 12−point font.
(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: Be-
ginning on or after XX/XX/XXXX.
(D) The phone number listed in this Part shall be the insurer’s cus-
tomer service phone number for consumers.
(3) Part II: Deductible
(A) Report the in−network and out−of−network deductibles here. If
there is no deductible, state “None” in the table. If there are different de-
ductibles 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, re-
place “In−Network” with “All Providers” and remove the Out−of−Net-
work column.
(B) Under 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 Ta-
ble. If there are no maximums, state “None” in the table.
(B) For “Out−of−Network,” select one of the three choices: (1) [Yes,
the cost−sharing will be higher. Contact your Plan]; (2) [No]; or (3) [Not
applicable]. If the choice selected is “Yes” include the additional text in-
to the SDBC.
(C) For EPO policies, state “Not Covered” in the out−of−network col-
umn. 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.
(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 pa-
tient
2. Bitewing X−ray: single radiographic image
3. Cleaning: prophylaxis − adult
4. Filling: resin based composite − one surface, anterior
5. Simple Extraction: extraction, erupted tooth or exposed root (eleva-
tion 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
Page 4
Galley
[List as applicable] Summary of what [List as applicable]
is not covered
or subject to a
limitation:
8. Ceramic Crown: porcelain/ceramic
9. Removable Partial Denture: maxillary partial denture − cast metal
framework resin denture bases (including any conventional clasps, rests
and teeth)
(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 co-
payment or coinsurance applicable for each service. If the plan has a de-
ductible 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 spe-
cialist (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) and page num-
ber(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 illus-
trative 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 for 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 Ap-
plicable” 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 cal-
culation. 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 in-
clude all items listed in these instructions under (j)(6)(E), numbers 1−4,
above.
NOTE: Authority cited: Section 10603.04, Insurance Code. Reference: Sections
10133.8, 10290 and 10603.04, Insurance Code.
HISTORY
1. New 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 emergen-
cy 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.