We know it can be very hard to understand dental benefits. At Soulsmile, we are happy to bill insurance as a courtesy to our patients. Our team encounters dozens of different insurance providers, all with multiple plans and “levels” making it impossible to know the details of each one. We always encourage our patients to get to know their dental plan to have the best estimate of what is covered. The only problem with this is also needing to know what many of the insurance terms they throw around even mean. In this blog, we are going to help you understand some of the terms and ideas behind dental insurance so you can feel confident in understanding your benefits.
Annual Maximum
This is the grand total that your plan will pay for dental services for an individual or a family (if you’re under a family plan). Most “years” reset January 1st, but occasionally we see them reset at the enrollment date, so you’ll want to check on this for your plan.
Basic or Minor Services
This is one of a few common categories of dental services defined by insurance companies (along with Preventative and Major, each explained below). Basic services typically fillings, sealants, extractions, periodontal treatment and sometimes root canals. Usually, the same coinsurance (patient payment portion) percentage applies to all services in a group such as Basic.
Closed Network Plan
If you are enrolled in a closed network plan you must see a preselected dentist in order to receive benefits. If you go to an out-of-network office with this type of plan, you’ll need to pay for 100% of your services. More commonly, you’ll find a breakdown of coverage for both in-network and out-of-network dentists.
Coinsurance
This is your share of the cost of services, typically marked as a fixed percentage, of the contract allowance or “usual and customary” fee (see definition below). For example, a benefit paid at 80% by the plan leaves a 20% coinsurance obligation for the patient. This coinsurance applies after a required deductible is met (if necessary).
Contracted Dentist
A dentist who has a contract with your network. In this case, the dentist agrees to accept the insurance carrier’s fees as payment in full for services to plan members. Sometimes referred to as network dentist or participating dentist.
Deductible
A dollar amount that each patient enrolled in a plan (or family under a family plan) must pay before the insurance company begins paying benefits.
Diagnostic and/or Preventive Services
A category of services that usually includes exams, routine cleanings, X-rays and fluoride treatments. These fees are usually covered at 100% for in-network plans and 80% for out-of-network plans. Often times the difference for a patient to choose a dental office like Soulsmile, that might be out-of-network, for a normal exam and cleaning can be ~$20.
Effective date
The date that benefits begin for an enrolled patient. Please be sure to get this information from your insurance company if it is a new insurance plan. We often see patients’ plans with a wait period (often 6 months or 12 months after starting a new job and insurance plan). Sometimes the wait period only applies to selected categories of services.
Eligibility
Circumstances or conditions that determine who and when a patient is covered by the insurance plan. These may include the length of employment, job status, length of time an enrollee has been covered, dependency, dependents’ age.
Lifetime Maximum
The total dollar amount a plan will pay for care for the life of the enrollee or the plan. This type of limitation usually applies to a specific service such as orthodontic treatment.
Limitations and Exclusions
Dental plans often opt to not cover every dental procedure. Each carrier can provide you with a list of conditions that limit or exclude coverage under your plan. Limits are often related to frequency (for example, no more than two cleanings in a 12 month period).
Major Services
This category of services usually includes crowns, dentures, implants and oral surgery.
Out-of-Pocket Costs
Any amount the patient is responsible for, such as coinsurance, deductibles, costs above the annual maximum or cost for services not covered by the plan.
Pre-Treatment Estimate
Pre-treatment estimates are a written estimate of benefits provided by an insurance company in advance of proposed treatment. These are a very reliable way of finding out for a patient exactly what payment they would be responsible for at the time of service. Sometimes referred to as a predetermination.
Provider
Any licensed dentist who performs dental health services for the patient. This can also include dental specialists.
Usual and Customary Fees
This refers to the dollar amount set by an insurance carrier as a reasonable cost for a service. This term only comes into play when you are seeing a dentist who is out-of-network. This may also be referred to as the “allowed amount”. Let’s say your plan has an allowed amount of $98 for a cleaning, and your dentist’s fee is $111. The plan will pay 80% of $98, not $111. The difference in price will be the patient’s responsibility.