Section 1300.63.4 - Summary of Dental Benefits and Coverage Disclosure Matrix (California Code of Regulations)

§ 1300.63.4. Summary of Dental Benefits and Coverage Disclosure Matrix

(a) Applicability

(1) This section shall apply to health care service plans or specialized health care service plans, issuing, selling, renewing, or offering a contract that covers the provision of dental services.

(2) This section shall not apply to any health care service plan contract for medical, surgical, and hospital services that offers dental services as a dental benefit within the medical, surgical, and hospital services contract.

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

(1) "Group Contractholder" has the same meaning as in title 28, California Code of Regulations, section 1300.65(a)(6).

(2) "Plan" means a health care service plan or a specialized health care service plan, including its solicitors and representatives, that issues, sells, renews, or offers a contract that covers dental services.

(3) "Plan year" means a calendar year or a period of time as designated in the contract between the individual or group and the plan offering dental benefits.

(c) Summary of Dental Benefits and Disclosure Matrix Filing Requirements

(1) A plan subject to this section shall use the Summary of Dental Benefits and Coverage Disclosure Matrix (SDBC), DMHC 10-278, dated 12/20, as incorporated herein by reference, and published by the Department on its website: www.dmhc.ca.gov. The plan shall use the SDBC for each dental product it issues, sells, renews, or offers. The plan's SDBC shall comply with the Instruction Guide for Summary of Dental Benefits and Coverage Disclosure Matrix, DMHC 10-277, dated 12/20, as incorporated herein by reference, and published by the Department on its website: www.dmhc.ca.gov.

(2) A plan shall use only a SDBC that reflects benefits including cost-sharing, exclusion, and limitation provisions the Department approved pursuant to Health and Safety Code section 1351 and Health and Safety Code section 1352 and implementing regulations.

(3) Within 15 months of the effective date of this section consistent with Health and Safety Code section 1363.04(a), the plan shall file an electronic affirmation with the Department stating its SDBCs comply with the provisions of this section for each Department-approved dental product it issues, sells, renews, or offers.

(4) As part of a plan's initial license application filed pursuant to Health and Safety Code section 1351, a plan shall file a SDBC with the Department that reflects benefits, including cost-sharing, exclusion, and limitation provisions, for each dental product it intends to issue, sell, or offer.

(5) After licensure, a plan shall file a SDBC for each dental product it proposes to add or amend in accordance with Health and Safety Code section 1352 in the following instances:

(A) When proposing a new dental product, the plan shall file a SDBC reflecting the proposed benefits, including cost-sharing, exclusion, and limitation provisions;

(B) When requesting an amendment to a previously approved SDBC, the plan shall file a SDBC reflecting the amended benefits including cost-sharing, exclusion, and limitation provisions; and

(C) When proposing an amendment to an SDBC for which it affirmed compliance in accordance with subdivision (c)(3), the plan shall file a SDBC reflecting the proposed benefits including cost-sharing, exclusion, and limitation provisions.

(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. All plans subject to this section shall provide in the following manner a SDBC for each dental product offered in the individual market:

(A) For prospective individual enrollment.

1. When presenting any dental product contract for examination or sale to a prospective individual enrollee, the plan shall provide the individual an applicable SDBC for each dental product for which the individual is eligible at the same time it provides other disclosure materials, including the Evidence of Coverage.

2. When requested, a plan shall provide a SDBC for each applicable dental product for which the prospective individual enrollee is eligible, including any other disclosure materials the plan 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 plan shall provide the individual prospective enrollee with the applicable SDBC and any other disclosure materials the plan is required to provide.

2. If the plan provided an applicable SDBC to the prospective individual enrollee before the individual applied for coverage, the plan shall be in compliance with (d)(1)(B)1. if the applicable SDBC the plan provided to the individual does not differ from the plan's applicable SDBC in effect at the time of application. If the plan's applicable SDBC in effect at the time of application differs from the SDBC the plan provided to the individual, the plan 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 plan's applicable SDBC in effect between the date of application and the first day of coverage differs from the SDBC the plan provided to the individual prospective enrollee pursuant to (d)(1)(B)1., the plan 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 plan year.

(E) Method of Delivery. Plans 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 plan shall notify the enrollee a paper copy is available free of charge and inform the enrollee how to contact the plan for a paper copy or with questions.

3. If provided on the plan's website, the plan shall:

a. Place the SDBC in a location on the plan's 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 group that a paper copy is available free of charge and inform the enrollee how to contact the plan for a paper copy or with any questions.

(2) Group Contracts. A plan subject to this section offering group coverage shall provide a SDBC for each dental product it offers in the group market in the following manner:

(A) Delivery of SDBC. When a group contracts for coverage, the plan shall provide the applicable SDBCs to the group upon delivery of the completed health care service plan contract. The SDBC shall be provided at the same time the plan provides other disclosure materials, including the applicable Evidence of Coverage.

(B) Changes to the SDBC. If the plan's applicable SDBC in effect between the date the group signs contract for coverage and the group's first day of coverage differs from the SDBC the plan provided to the group pursuant to (d)(2)(A), the plan 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 plan 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 SDBC shall be provided no later than 30 days before the first day of the plan year.

(D) Method of Delivery. Plans 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. The plan shall notify the group a paper copy is available free of charge and inform the group how to contact the plan for paper copy or with any questions.

3. If provided on the plan's website, the plan shall:

a. Place the SDBC in a location on the plan's 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 a paper copy is available free of charge and inform the group how to contact the plan for paper copy or with any questions.

(3) Group Contractholder Obligations.

(A) Prior to enrollment. When offering coverage to eligible subscribers, the group contractholder shall provide an applicable SDBC for each dental product it is offering to each person eligible to be a subscriber under the group contract at the same time the group contractholder provides other disclosure materials.

(B) Upon application for dental coverage. The SDBC shall be provided by the group contractholder to each subscriber 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 subscriber by the group contractholder within 7 business days following receipt of the application for coverage.

2. If the group contractholder provided an applicable SDBC to the subscriber prior to the subscriber applying for coverage, the group contractholder shall be in compliance with (d)(3)(B)1. if the SDBC the group contractholder provided to the subscriber does not differ from the applicable SDBC in effect at the time of application. If the SDBC the group contractholder provided to the subscriber differs from the applicable SDBC in effect at the time of application, the group contractholder shall provide the current SDBC to the subscriber 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 contractholder provided to the subscriber pursuant to (d)(3)(B)1., the group contractholder shall provide the current applicable SDBC to the subscriber no later than the first day of coverage.

(D) Upon 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 prior to the first day of the plan year.

(E) Method of Delivery. Group contractholders 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 contractholder shall notify the subscriber that a paper copy is available free of charge and shall provide information on how to contact the plan for a paper copy or with any questions.

3. Direct the subscriber to the plan's website for a copy of the SDBC.

(e) Special Enrollment. A plan shall provide the SDBC to enrollees qualifying for coverage under special enrollment periods at the same time it provides other disclosure information, including the Evidence of Coverage.

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

(g) The plan shall ensure all group contractholders comply with the requirements of this section.

(h) If a plan delegates any of the requirements under this section to another entity, the plan remains responsible for ensuring its delegate or delegates complies with the provisions of this section.

(i) The SDBC provided pursuant to this section shall comply with the requirements of Health and Safety Code section 1367.04 and Title 28, California Code of Regulations section 1300.67.04.

(j) Failure to comply with the requirements of this regulation may constitute a basis for disciplinary action against the health plan. The Director shall have the civil, criminal, and administrative remedies available under the Knox-Keene Act, including section 1394.

(1. New section filed 1-25-2021 as an emergency; operative 1-25-2021. Pursuant to Health and Safety Code section 1363.04(f), this action is a deemed emergency and exempt from OAL review. Expiration date of emergency action extended 60 days (Executive Order N-40-20) plus an additional 60 days (Executive Order N-71-20) (Register 2021, No. 5). A Certificate of Compliance must be transmitted to OAL by 9-24-2021 or emergency language will be repealed by operation of law on the following day.)

Note: Authority cited: Sections 1344 and 1363.04, Health and Safety Code. Reference: Section 1363.04, Health and Safety Code.

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