Summary of Dental Benefits and Coverage Disclosure Matrix (SDBC)
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.
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.
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.
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.]
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] |
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] |
Cal. Code Regs. Tit. 10, § 2239.10
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.
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).