§ 1300.63.4. Summary of Dental Benefits and Coverage Disclosure Matrix.
28 CA ADC § 1300.63.4Barclays Official California Code of RegulationsEffective: January 1, 2023
Effective: January 1, 2023
28 CCR § 1300.63.4
§ 1300.63.4. Summary of Dental Benefits and Coverage Disclosure Matrix.
(1) A plan subject to this Rule shall use the Summary of Dental Benefits and Coverage Disclosure Matrix (SDBC), DMHC 10-278, dated September 1, 2022, 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 September 1, 2022, as incorporated herein by reference, and published by the Department on its website: www.dmhc.ca.gov.
(6) Within six months after January 1, 2023, the plan shall file for each product type the plan offers a template SDBC that is representative of each SDBC that it has provided or is required to provide by Health and Safety Code section 1363.04 or subsection (d) of this Rule unless it has previously filed the SDBC with the Department and received approval.
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. 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.
(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 a contract for coverage and the group's first day of coverage differs from the SDBC the plan provided to the group pursuant to subsection (d)(2)(A) of this Rule, 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.
(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.
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 subsection (d)(3)(B)1. of this Rule 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 subsection (d)(3)(B)1. of this Rule, 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.
Credits
Note: Authority cited: Sections 1344, 1363.04 and 1386, Health and Safety Code. Reference: Section 1363.04, Health and Safety Code.
History
1. New section filed 9-1-2022; operative 1-1-2023 (Register 2022, No. 35). For prior history, see Register 2022, No. 15.
This database is current through 4/26/24 Register 2024, No. 17.
Cal. Admin. Code tit. 28, § 1300.63.4, 28 CA ADC § 1300.63.4
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