Insurance terms you should know before your next dental visit

Annual maximum

The total dollar amount that a plan will pay for dental care incurred by an individual enrollee or family (under a family plan) in a specified benefit period, typically a calendar year.

Copayment

A fixed dollar amount that an enrollee under certain dental plans is required to pay at the time the service is rendered.

Deductible

A dollar amount that each enrollee (or, cumulatively, a family for family coverage) must pay for certain covered services before the dental insurance begins paying benefits.

Diagnostic and preventive services

A category of dental services in an open network dental benefits contract that usually includes oral evaluations, routine cleanings, x-rays and fluoride treatments. (This may vary by contract.) Typically, the same coinsurance percentage applies to all services grouped under diagnostic and preventive services.

Dual coverage

When dental treatment for an enrollee is covered by more than one dental benefits plan, such as when dental services are provided to a child who is covered by both parents’ benefit plans.

Effective date

The date a dental benefits contract begins; may also be the date that benefits begin for a plan enrollee.

Eligibility

The circumstances or conditions that define who and when a person may qualify to enroll in a plan and/or a specific category of covered services. These circumstances or conditions may include length of employment, job status, length of time an enrollee has been covered under the plan, dependency, child and student age limits, etc.

Fee-for-service

Compensation paid to dentists based on an amount per service. A fee-for-service plan generally permits enrollees to freely select a network or non-contracted dentist to provide the service. Freedom of choice

A plan feature that permits an enrollee to visit any licensed dentist and receive benefits for covered services.

Health maintenance organization

An entity that is authorized to issue a benefit plan in which enrollees receive all or most treatment through a pre-selected or pre-assigned dental office. The dentist receives a monthly capitation payment for each patient that selects or is assigned to that office no matter how many services that patient receives. (See “Capitation”)

In-network/Out-of-network

Services provided in a plan either by a contracted or non-contracted dentist. In-network dentists have agreed to participate in a plan and to provide treatment according to certain administrative guidelines and to accept their contracted fees as payment in full. Different plans are served by distinct dentist networks. Delta Dental PPO dentists are in-network dentists for Delta Dental PPO plans. Delta Dental Premier dentists are in-network for Delta Dental Premier plans. DeltaCare® USA are in-network for DeltaCare USA plans. Non-Delta Dental dentists are out-of-network for all of these plans.

Indemnity/indemnity plan

(See “Fee-for-service”)

Lifetime maximum

The cumulative dollar amount that a plan will pay for dental care incurred by an individual enrollee or family (under a family plan) for the life of the enrollee or the plan. Lifetime maximums usually apply to specific services such as orthodontic treatment.

Limitations and exclusions

Dental plans typically do not cover every dental procedure. Each plan contains a list of conditions or circumstances that limit or exclude services from coverage. Limitations may be related to time or frequency (the number of procedures permitted during a stated period) — for example, no more than two cleanings in 12 months or one cleaning every six months. Exclusions are dental services that are not covered by the plan.

Major services

A category of dental services in an open network dental benefits contract that usually includes crowns, dentures, implants and oral surgery. (This may vary by contract.) Typically, the same coinsurance percentage applies to all services grouped under major services.

Network

A panel of dentists that contractually agree to provide treatment according to administrative guidelines for a certain plan, including limits to the fees they will accept as payment in full.

Open access

A plan feature that allows enrollees to visit the dentists of their choice (freedom of choice). Also sometimes used to describe an enrollee’s ability to seek treatment from a specialist without first obtaining a referral from his/her primary care dentist.

Open enrollment

A period (usually a two-week or one-month period during the year) when qualified individuals (eligible employees) can enroll in or change their choice of coverage in group benefits plans.

Open network plan

A type of dental plan where enrollees can visit any licensed dentist and can change dentists at any time without contacting the benefits carrier.

Out-of-pocket costs

Any amount the enrollee is responsible for paying, such as coinsurance or copayments, deductibles and costs above the annual maximum.

Usual fee

The amount commonly charged for a particular service by a dentist.

Waiting period

A stated period of time that a person must be enrolled in a plan before being eligible for benefits or for a specific category of benefits.