When you’re new to dental benefits, you’ll likely get a lot of new and unfamiliar terminology thrown your way. It may seem like a complex, overwhelming amount of information right now, but don’t worry — it’s not as complicated as it appears.
Before you schedule your first dental appointment under the new plan, go over the definitions for some of the basic insurance terms you’ll come across. And feel free to reference this post any time you need a refresher!
Your Glossary of Common Dental Benefits Terms
The maximum age at which members are covered for specific dental services. Typically, you only have an age limit for fluoride, sealants, and orthodontic work such as braces; the majority of covered dental services don’t have age limits.
The maximum amount of money your dental plan will pay for covered services per benefit year. You pay out of pocket for any dental services received after the maximum is met. The annual max amount will depend on your plan.
The 12-month period in which you can receive benefits from your dental plan. It’s also the period of time in which your deductible and annual maximum apply. If you keep the same dental plan next year, the new benefit year will begin after the current one concludes.
A request for payment sent to your dental benefits provider after receiving a covered service.
The percentage of a covered service you’re responsible for paying after you’ve paid for your deductible. You may see this as the percentage your dental plan covers; the remaining percentage is your coinsurance.
The amount you’re required to pay for covered dental services before your benefits provider will pay. If your plan also covers members of your family, you’ll have a family deductible. This is the amount your family must pay before benefits kick in. It’s important to note that every family member will still have an individual deductible. Coverage begins for individuals when either deductible is met.
Family members, usually your spouse and children, who are covered under your dental plan.
The date when your dental coverage begins and you — and any dependents — can start using your plan.
Explanation of benefits
A statement that details a dental claim. It explains what treatments or services your benefits provider covered and what you owe.
The maximum number of times a service is covered within a benefit year. For example, your plan may cover two dental cleanings per benefit year.
Refers to a dental practice that is a part of your benefits plan’s network. You will typically pay less out of pocket when visiting an in-network dentists because your insurance will cover a higher percentage of the cost and the dental provider will charge lower rates.
The period, usually ranging between two weeks to a month, during which you can make changes to your dental benefits. This occurs once per year.
Refers to a dental practice that is not part of your benefits provider’s network. You will typically pay more out of pocket when visiting an out-of-network dentist. However, if your preferred dentist is out of network and you wish to keep them as your dental care provider, your insurance may still cover a portion of the service. The percentage covered depends on whether you have a MAC or UCR plan.
Orthodontics lifetime maximum
The maximum amount of money a dental plan will pay for orthodontic treatments, such as braces, during an individual’s lifetime. You must pay out of pocket after meeting this maximum.
An acronym for “preferred provider organization.” A PPO plan has a network of providers who offer dental care to its members.
The amount you’re required to pay your benefits company for dental coverage, usually on a monthly basis. Your employer may cover a portion of this cost.
The categories of dental care, which dictate how much your dental insurance covers for specific procedures. They are: diagnostic and preventative (e.g., teeth cleanings and X-rays), basic (e.g., fillings and root canals), major (e.g., crowns and dentures), and orthodontic (e.g., braces).