Dental Benefits Common Terms

Not sure what they all mean? We’ve got you covered.

Finding the right dental coverage can sometimes feel like you’re piecing together an elaborate puzzle. Still, the most important pieces of the big picture are often found in the terms used to outline a plan’s features.

Annual Maximums
This is the total dollar amount a dental plan will pay during the plan year. Your employer or dental plan makes the final decision on maximum levels of payment. You are expected to pay copayments and any costs above the annual maximum. An annual maximum is usually $1,000 or $1,500 and has not changed much in the last 50 years. These totals are usually for one person. Each family member usually has a separate annual maximum.

Assignment of Benefits
This takes place when you authorize the dental plan to forward payment for a covered procedure directly to the treating dentist.

Cost Sharing
When the treatment cost is shared by the plan and the enrollees, the cost of the plan will be much less. Different ways to share costs include deductibles, co-payments, frequency limitations, annual maximums and use of a fee schedule to calculate benefit payments.

Deductibles
A deductible is the amount of money that you must pay before a benefit plan will pay for any service. (For example: If your deductible is $50, your plan kicks in once you’ve paid that much in related expenses.) Most dental plans are based on a calendar year (January through December) which means you pay a deductible once each year. It can take more than one service or visit to satisfy the entire deductible. Depending on your dental plan’s design, some services (such as cleanings and diagnostic services) may not be subject to any deductible.

Exclusions
Exclusions are dental services that are not covered by the plan.

Frequency Limitations
Each plan contains a list of conditions or circumstances that limit or exclude services from coverage. Limitations determine how often a particular service is covered and are related to time or frequency (the number of procedures permitted during a stated period). For example, no more than two cleanings in 12 months or one cleaning every six months.

Least Expensive Alternative Treatment (LEAT)
If a plan has a LEAT clause, the plan will only pay for the least expensive treatment if there is more than one option to treat the condition.

Pre-existing Conditions
A dental plan may not cover conditions that existed before you enrolled in the plan. For example, benefits may not be paid for replacing a tooth that was missing before the effective date of coverage.

Leave a reply