With open enrollment underway, you might find yourself tripping over a lot of insurance industry jargon – terms like “annual maximum,” “HMO,” and “waiting period.”
It can be a lot to wrap your head around.
But we want to make sure armed with all the knowledge you need to make the choices that are best for both your oral and overall health. So, we’re breaking down some of the most common dental insurance terms you’ll run across when choosing the plan that works for you.
Need dental coverage? Shop our Individual & Family™ plans to find the coverage that’s right for you!
Get Your Quote
Annual Maximum
This is the total amount your dental plan will cover within a specific amount of time, which is typically one year.
Claim
Think of this like the bill you receive at a restaurant at the end of your meal. Only, you don’t get the bill, it’s sent to your insurance provider (i.e. Delta Dental of Washington), who covers the cost, so you don’t have to wait to be reimbursed.
Coinsurance
The amount you’re responsible for if your insurance doesn’t cover the cost of a procedure 100%. For example, let’s say your plan covers the cost of a filling at 50% of the cost, you would pay the remaining 50%. Unlike a copay (see below), the amount is determined by a fixed percentage, rather than a fixed number.
Copay
A copay is similar to coinsurance but rather than your share being determined by a fixed percentage of the total cost, it’s a fixed dollar amount. Which means, regardless of the cost of a procedure the amount you pay stays the same. Let’s use our filling example:
On our Clear Plan, the cost is fixed at $115 and Delta Dental of Washington pays the rest.
Coordination of Benefits (COB)
If you are covered on two dental insurance plans, this is the process your insurance providers will use to determine how much each will pay to cover a certain dental procedure. This way, neither provider pays more than 100% of the procedure cost.
Deductible
This is the total amount you have to pay each year before your insurance provider will start covering your care.
Dual Coverage
This describes the instance where you or a family member – your child, for example – is covered by more than one insurance plan. (See Coordination of Benefits)
Effective Date
Another way of saying ‘your plan’s start date.’ This is the date when your coverage begins or when coverage begins for a family member on your plan.
Explanation of Benefits (EOB)
An EOB is the document you receive from your insurance provider explaining the procedure(s) you had done, the amount your insurance did and didn’t cover, and any out-of-pocket costs you might be responsible for. Your EOB isn’t a bill.
HMO (Health Maintenance Organization)
A care network that manages your insurance plan. They work very similar to medical HMOs in that your choice of dentist is predetermined based on those contracted to the network. Unlike PPOs (Preferred Provider Organization), HMOs typically have lower monthly premiums.
In Network/Out of Network
This determines whether or not your dentist is contracted or non-contracted. When your dentist is in-network, they’ve agreed to provide you care according to your insurance provider’s specific guidelines. They’ve also agreed to certain contracted fees, which they accept as payment for any procedure they perform.
Lifetime Maximum
Similar to an annual maximum, the lifetime maximum is the total amount of coverage you’ll receive for the total amount of time you’re enrolled in your plan, not just within a 12-month time span. Usually, this applies to specific treatments, like orthodontia.
Limitations and Exclusions
Dental plans don’t cover every procedure. Usually, they include a list of conditions or circumstances that limit or exclude certain things on the plan. For example, your plan may limit the number of cleanings per year to 2, or 1 every 6 months. Anything not covered by your plan is called an exclusion.
Network
This is the administrative group that your dentist belongs to. The most common networks are HMO and PPO. We also offer a third network, called Premier so you get more dentists to choose from.
Open Enrollment
A specific time period where eligible individuals can sign up for or change their coverage. Most of us are used to this when we sign up for coverage through our employers, but this also occurs once a year for Medicare-eligible Americans. (pssst…open enrollment is going on RIGHT NOW!)
Participating Dentist
This refers to dentist that are within your specific network.
Preffered Provider Organization (PPO)
Unlike an HMO, preferred provider organizations allow you to visit any dentist, whether they’re in-network or not. PPOs usually have higher monthly premiums than HMOs but usually have lower out-of-pocket costs.
Predetermination
Sometimes called a “pre-treatment estimate,” this is a written estimate of what a procedure would cost and the amount of coverage available. Important to note: these are simply estimates, which are subject to your plan’s limitations or your eligibility at the time you go in for the procedure.
Waiting Period
This is the amount of time you must be enrolled in your plan before your insurance provider will begin to cover you.
Remember, this post just covers some of the most common dental insurance terminology you’ll come across and that there’s still a ton that goes into choosing a dental plan. For more information on topics like “How to Get Dental Insurance” and “How Does Dental Insurance Work?” head on over to our Dental Insurance 101 page.
Need dental coverage? Shop our Individual & Family™ plans to find the coverage that’s right for you!
Get Your Quote
