The Spirit Dental Blog | Stay In The Know

Dental Insurance Terms That You Need To Know

When shopping for dental insurance, you may encounter a number of terms that are unfamiliar to you. Understanding what these terms mean and how they affect your coverage is important if you want to make sure that you get the most for your money.

Annual Maximum

This is the maximum amount in dollars that an insurance plan will pay towards dental care for an individual or family enrolled in a plan during a calendar year.

Co-Payment

This is the portion of the fee for care that you are obliged to pay, either before or after your insurance company has paid its agreed-upon portion.

Coinsurance

This is your responsibility, expressed as a fixed percentage, of the cost of care. For example, a 20 percent coinsurance rate means that your insurance company covers 80 percent and you pay for the remaining 20 percent. This applies after your deductible has been reached.

Covered Services

These are the services performed by a dentist that your insurance company has agreed to cover as a part of your policy.

Deductible

This is the amount in dollars that you are responsible for paying for dental care before the insurance company will begin to pay benefits. For example, if your policy has a $1000 deductible, you will only receive benefits from your insurer after you have paid for $1000 of care. This amount is reset at the beginning of the year.

Diagnostic and Preventive Services

These are basic dental services that include such procedures as cleanings, examinations, and X-rays. Most insurance plans cover all or almost all of the cost of such services.

Explanation of Benefits

This document explains which services were covered and how much coverage was applied to an individual claim.

Lifetime Maximum

This is a maximum amount of benefits that will be paid for certain services during the life of the enrollee. This most commonly applies to orthodontic treatment.

Limitations and Exclusions

Most dental insurance does not cover every possible form of dental treatment. A particular policy will limit the amount of coverage it provides and list procedures that are excluded from coverage. These may be based on the frequency of care or the type of procedure that is performed.

Network

This is a group of providers who participate in a certain dental insurance plan. Seeing an in-network dentist means that the plan will cover more of the cost of care. If you see an out-of-network dentist, your insurance company may pay less of the cost of treatment, or you may have to pay for the entire cost out of your own pocket.

Out-of-pocket Costs

These are costs that you must pay on your own, such as co-payments, coinsurance, and deductibles. Once you have reached your annual maximum, for instance, you will have to pay any further costs out of your own pocket.

Waiting Period

This is the length of time that you have to wait after you enroll in a plan before you can begin to receive benefits.

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