Dental Insurance Glossary

Dental insurance is a type of coverage designed to help individuals manage the cost of dental care. Understanding the various terms associated with dental insurance can help individuals make informed decisions. The Dental Insurance Glossary* covers a comprehensive range of terms related to dental insurance products.

* See the Dental Insurance Glossary Terms of Use at the bottom of this page.

A

Alternative Benefit  

The benefit amount your insurance pays for a less expensive but acceptable dental treatment that meets the same need.

Annual Maximum  

The maximum dollar amount your insurance will pay for covered services within a calendar year. Once you reach this limit, you’ll be responsible for any additional costs.

B

Balance Billing

When a provider bills you for the difference between their charge and the allowed amount by your insurance. This happens when using out-of-network providers.

Basic Services 

Common dental treatments such as fillings, extractions, and simple restorative procedures. These services typically require coinsurance or copayments.

Benefit Schedule 

A list detailing the specific amounts that the insurance will pay for various covered services, regardless of the actual charges.

Benefit Year

The 12-month period during which your dental insurance benefits reset. It typically aligns with the calendar year but can vary.

C

Capitation Plan  

A dental plan in which dentists receive a set amount for each enrolled patient, regardless of whether that patient seeks care.

Claim

A request for payment that you or your dentist submits to the insurance company for services you believe are covered.

Claim Form 

The document that must be completed and submitted to request reimbursement from the insurance company for covered services.

Coinsurance  

The percentage of covered dental expenses you’re responsible for after meeting your deductible. For instance, if your coinsurance is 20%, you pay 20% of the cost, and the insurance covers the remaining 80%.

Coordination of Benefits (COB)

When you have multiple insurance policies (e.g., through your employer and your spouse’s employer), COB determines which plan pays first and how much the secondary plan covers. This process ensures coverage without exceeding the cost of services.

Copayment (Copay)

A fixed fee you pay for specific dental services (e.g., cleanings, fillings) at the time of the visit. Copayments vary based on the service provided.

Covered Charges  

The fees for dental services that are covered under your dental plan, subject to limitations and conditions of your policy.

D

Deductible  

The initial out-of-pocket amount you must pay before your insurance coverage kicks in. For example, if your deductible is $100, you’ll pay the first $100 of covered dental expenses, and then the insurance will cover the rest.

Dental Health Maintenance Organization (DHMO)

A type of dental plan where members must use a network of dentists who are paid a fixed fee for each enrolled patient. These plans often have lower premiums but limited provider choices.

Dependent Coverage  

Extending dental insurance coverage to family members (spouse, children) under the same policy.

DVH Products (Dental, Vision, Hearing Plans)  

Insurance plans that combine coverage for dental, vision, and hearing care. These plans offer a comprehensive solution for maintaining overall oral and sensory health.

E

Eligibility  

The requirements that must be met for a person to be covered by a dental insurance plan, such as employment status or relationship to the policyholder.

Exclusions  

Services or conditions not covered by your dental insurance policy. It’s essential to understand what’s excluded to avoid unexpected costs.

Explanation of Benefits (EOB) 

A statement sent by the insurance carrier after a dental visit, detailing the services provided, costs, and how much the insurance covered.

F

Fee-for-Service Plan  

A type of dental insurance plan where the dentist is paid a fee for each service performed, rather than receiving a salary or capitation payment.

I

Incentive Plan 

A type of dental plan where coverage levels increase when you maintain regular dental visits and do not exceed certain limits on claims.

Indemnity Plan  

A type of dental plan that reimburses you or the provider for covered services, regardless of which dentist you see. You may need to pay upfront and submit a claim for reimbursement.

L

Lifetime Maximum  

The total amount an insurance policy will pay over your lifetime for specific services (e.g., orthodontics). Once this limit is reached, any additional costs are your responsibility.

M

Major Services  

More complex treatments, including crowns, bridges, dentures, root canals, and orthodontics. These services often have higher coinsurance or copayments.

N

Network  

Dentists and dental facilities that have agreements with the insurance carrier. In-network providers typically offer discounted rates to insured individuals.

Non-Covered Services  

Dental procedures that are not included in your dental insurance plan benefits. Patients must pay the full cost for these services.

O

Open Enrollment Period  

A specific time frame during which you can sign up for or make changes to your dental insurance plan without needing a qualifying event.

Orthodontics 

Dental treatment to correct misaligned teeth using braces, aligners, or other appliances. Coverage for these treatments may have a lifetime maximum.

Out-of-Network  

Dentists who are not part of the insurance carrier’s network. If you choose an out-of-network provider, your costs may be higher.

P

Point of Service (POS) Plan  

A dental insurance plan that combines elements of DHMO and PPO plans. Patients may need a referral from their primary dentist to see specialists.

Preferred Provider Organization (PPO)  

A type of dental insurance plan that offers a network of dentists who provide care at reduced rates. Members can see out-of-network providers but at a higher cost.

Preauthorization  

Obtaining approval from the insurance carrier before undergoing specific treatments (usually major procedures). Preauthorization ensures coverage eligibility.

Premium  

The amount you pay to the insurance carrier regularly (usually monthly) to maintain your dental insurance coverage. This amount can vary based on the plan, coverage level, and number of people covered.

Preventive Services  

Routine dental care aimed at preventing oral health issues. Examples include cleanings, X-rays, and fluoride treatments. These services are often covered at no cost or a low copayment.

Provider Directory  

A list of dentists and specialists within the insurance network. Check the directory to find an in-network provider, ensuring you manage costs effectively.

Q

Qualifying Life Event 

A life change that allows you to enroll in or make changes to your dental insurance outside the open enrollment period. Examples include marriage, birth of a child, or loss of other coverage.

R

Reasonable and Customary (R&C) Fees 

The standard rates that insurance companies use to determine the amount they will pay for a specific dental service in a particular geographic area. If your dentist charges more than the R&C fee, you may have to pay the difference.

U

Usual, Customary, and Reasonable (UCR) Fees  

The standard rates that insurance companies use to determine the amount they will pay for a specific dental service in a particular geographic area. If your dentist charges more than the UCR fee, you may have to pay the difference.

W

Waiting Period 

The time you must wait after enrolling in a dental insurance plan before certain services (e.g., major procedures) are covered. Waiting periods vary by carrier and plan.

For more detailed explanations and the most current information, please consult your insurance policy documents and contact your insurance provider directly. It's also beneficial to review other reliable sources and speak with dental professionals to ensure you have a comprehensive understanding of your dental insurance coverage and options.

The Dental Insurance Glossary is intended for informational purposes only and should not be considered dental or legal advice. Individuals and businesses should consult with a qualified dental professional or advisor before making any decisions regarding dental insurance. The terms included in this glossary may be updated periodically to reflect the latest changes and additions. For the most current and personalized advice, always seek professional guidance.

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