Insurance Terms

Birthday rule

The birthday rule is the commonly accepted rule for determining the order of primary and secondary payment of a dependent child’s dental treatment when the child is covered by both parents' dental plans. This rule states that the "primary" program (the one which pays first) is the one covering the parent whose month and day of birth falls first in the calendar year.

Cafeteria plan

A benefit program in which employees are given the ability to choose from a selection ("menu") of benefit plans. Also known as "flexible benefits."

Capitation

The prepaid amount that a network dentist receives as compensation for providing most dental services to enrollees assigned to their office. Compensation is paid "per capita"for each enrolled patient rather than on a per service basis. Typically when a dentist receives capitation, enrollees pay a predefined copayment for each dental procedure instead of coinsurance.

Contract year

The 12-month period over which a group’s deductibles, maximums and other provisions apply. This may or may not be the same as a calendar year. Also known as the benefit year. Most Delta groups now calculate benefits on a calendar year basis.

Coordination of Benefits ("COB")

When dental treatment is covered by more than one benefit plan, the dental plans coordinate their respective benefits so that no more than 100 percent of the total covered expense is paid.

Copayment

A fixed dollar amount that the enrollee is responsible for paying to the dentist's office usually at the time the service is rendered.

Coinsurance

The share of a dentist’s fee that an enrollee is responsible for paying, expressed as a fixed percentage. For example, a benefit paid at 80% by the plan creates a 20% coinsurance share for the enrollee. Coinsurance usually applies after the enrollee has satisfied the deductible.

Deductible

A dollar amount that an enrollee and/or the enrollee's family (for family coverate) must pay for certain covered services before the dental plan begins paying benefits. In most programs, deductibles must be met each year.

Dual choice

An option offered by Delta Dental to group customers that allows the group's enrollees to select from two or more types of dental plans. Also called "dual option."

Dual coverage

When an enrollee has coverage under more than one benefit plan. The plans will determine the order of payment and how to coordinate the benefits for covered treatment.

Enrollee

A person who is covered under a dental benefit plan. There are usually two types of enrollees —primary enrollees (e.g. the person who purchased the coverage or an employee of a group that purchased coverage) and dependent enrollees. The coverage contract defines who may be a dependent enrollee.

Exclusions

Dental care services not covered by a dental benefits plan.

Fee-for-service

A plan design in which the dentist is reimbursed for each service, rather than on a periodically paid fixed amount per patient. Delta Dental Premier^® and Delta Dental PPO^SM are fee-for-service programs.

Fee listing/filed fees

In some states Delta Dental Premier® dentists submit lists of their usual fees for approval or acceptance by Delta Dental. If those fees meet Delta Dental’s guidelines, they are used to calculate Delta Dental’s payment and the patient’s payment. Delta Dental Premier dentists may apply to update their fees up to once per year.

Guaranteed copayments

A feature of most Delta fee-for-service and HMO programs that protects you from unexpected expenses. For example, in a Delta Dental Premier fee-for-service program that pays an 80 percent benefit on covered services, you are guaranteed that your copayment will not be more than the remaining 20 percent, as long as you have gone to a Delta dentist. Other carriers pay 80 percent of some local allowance, leaving you with not only the 20 percent copayment, but also the difference between the local allowance and your dentist’s fee.

Health Maintenance Organization ("HMO")

A type of pre-paid benefit plan in which enrollees receive the majority of their covered treatment from the primary medical or dental office to which they are assigned. Commonly, the primary care provider receives a fixed monthly payment from the HMO (see Capitation) for each enrolled assigned patient, as opposed to payments for each service provided. Services requiring referral to a specialist must be preauthorized before benefits are payable. DeltaCare^® USA is a dental HMO-type program.

Incentive program

A program that promotes prevention by increasing coverage from one benefit period to the next as long as you visit the dentist regularly. For instance, cleanings might be covered at 70 percent during the first year, 80 percent during the second year and up to 100 percent as long as the program is used at least once a year.

Limitations

Provisions stated in the dental plan coverage contract which explain limits on coverage of certain benefits. Limitations are typically related to frequency (e.g., the number of treatments allowed), time (e.g. services covered within a given period), or age (e.g. orthodontic coverage for dependent children only).

Maximum

A dollar limit that the plan will pay for dental benefits received by an enrollee or the family (for family coverage). Some maximums apply to the lifetime of the benefit plan; others apply to a particular period of time (calendar year, benefit year, etc.) or particular services (such as separate maximum for orthodontic benefits).

Network dentist

A dentist who contracts with Delta Dental or any other member company of the Delta Dental Plans Association and agrees to accept Delta Dental’s determination of fees as payment in full for services provided to plan enrollees and to comply with Delta Dental’s administrative guidelines.

Non-duplication of benefits

A term used to describe a method of coordination of benefits where the secondary plan will not pay any benefits if the primary plan paid the same or more than what the secondary plan allows as a fee for that dentist.

Notice of payment

The statement you are mailed detailing how your claim payment was calculated. It is sometimes called an Explanation of Benefits.

Out-of-pocket costs

Any amount for dental treatment that an enrollee is responsible for paying, for example, copayments, deductibles and costs above the annual maximum.

Preferred Provider Organization ("PPO")

A type of fee-for-service program that allows an enrollee to choose to receive dental care from any licensed dentist but provides a financial incentive to choose dentists who participate in the plan’s dentist network.

Pre-existing condition

An example of a pre-existing condition is a tooth that was extracted prior to an enrollee receiving coverage. Many dental carriers routinely exclude coverage for pre-existing conditions; most Delta programs cover them.

Pre-treatment estimate

An estimate of how much of proposed treatment will be covered under an enrollee’s dental plan as of a particular date. A pre-treatment estimate is not a guarantee of payment. When the services are complete and a claim is received for payment, Delta Dental will calculate its payment based on the enrollee’s current eligibility, amount remaining in the annual maximum and any deductible requirements.