Making Sense Of It All

Dental Benefit Terms

To make smart decisions about a dental plan, it’s useful to understand some of the key words and concepts. Here are definitions for some of the most commonly used terms.

Annual Maximum
This is the maximum dollar amount a dental plan will pay toward the cost of dental care within a specific benefit period. The patient is personally responsible for paying costs above the annual maximum.

Balance Billing
When the amount that an insurance carrier will allow for a given procedure is less than a particular dentist charges, that dentist may demand the patient pay the difference in addition to whatever copayments are required. Generally, dentists in a network are not permitted to balance-bill their patients, so the best way to minimize this problem is to choose a carrier with large dentist networks.

Copayments (Coinsurance)
The percentage of cost paid by the insurance company for a specific type of treatment or service. What you pay is called the copayment. It is paid even after a deductible is reached. Copayments usually vary on the basis of category of treatment. For example, diagnostic and preventive services are often covered at 100%, basic restorative procedures (examples: fillings, simple
extractions) at 80%, and major restorative procedures (examples: crowns, fixed bridges) at 50%.

Deductibles
Just like your car insurance, the deductible is an amount paid by the patient before the insurance carrier will contribute to the bill. Dental plan deductibles usually renew on an annual basis.

Fully-insured
With a fully-insured plan, the group pays a monthly premium that is the same throughout the contract period, regardless of the amount of claims incurred by enrollees.

Limitations & Exclusions
Most dental plans include some form of limitations and exclusions. For example, your plan may cover no more than two cleanings per year, or it may exclude certain procedures from coverage.

Maximum Plan Allowance
Delta Dental’s term for the amount of payment we will consider for
each dental procedure. Delta determines this amount based on several factors, including a review of submitted charges and the dental inflation component of the Consumer Price Index.

Self-Insured
With a self-insured plan, the group pays an insurance carrier or third-party administrator a fee (usually based on per employee per month) to administer the program and to process claims, while the money to pay those claims comes directly from the group itself.

UCR (also known as U&C)
Stands for Usual, Customary and Reasonable (or Usual & Customary). Used by some insurance carriers as a term to define the amount of payment that the carrier will consider for each dental procedure.

Voluntary Plan
Dental plans in which the entire cost of the premium is paid by enrollees, with no
employer contribution.

Waiting Periods
Dental plans may include waiting periods before coverage becomes effective on
certain types of services, most commonly for major restorative procedures and/or orthodontia.
by-prevention model is more important than ever before.