Odds are, you never attended a class called “Dental Insurance 101” during all your schooling.
And, whether you’ve been using dental insurance for a while, or are just getting started, there are likely plenty of terms with which you may be unfamiliar.
That’s where we come in!
Below is a list of dental insurance terminology intended to help you best to choose and then use your insurance. This list is by no means comprehensive, but it will certainly get you started with the basics. We hope it helps!
Premium
A premium is the monthly amount you and/or your employer pays the insurance company during your coverage period so that you have insurance coverage.
Employee Contribution (of premium)
The portion of your insurance premium that you, the employee, are responsible for paying in order to obtain coverage.
Benefits
Items and services that your insurance covers.
For example, your insurance likely gives you two free exams/cleanings per insurance year.
Benefit Waiting Period
Depending on your insurance, you may have to be enrolled in the same plan for a certain amount of time before it covers a particular service.
For example, a plan may not cover periodontal care until you’ve been enrolled for at least 12 months.
Claim
When you visit your dentist, the office staff will submit a claim to your insurance company. This is a request for insurance to pay for your visit.
Patient portion (of the bill)
After your insurance claim is processed and paid for, there could still be a remaining charge that you have to pay. This will be billed to you directly from the dental office.
Deductible
Some services (like a regular exam/cleaning) may be 100% covered by your insurance. Other services might not be covered until you pay a certain amount per year. This is known as the deductible.
Once your calendar year or insurance year resets, you will begin paying the deductible amount all over again.
Coinsurance
While looking at your plan, if you see “50% coinsurance” next to “Fillings and Sealants,” for example, this means that your insurance will cover 50% of the cost of a filling after you have paid your deductible. You would be responsible for paying the other 50% of the cost directly to the dental office.
In other words, once you’ve met your deductible for a year, your provider will split coinsurance percentages with you.
Copayment/Copay
This is a flat rate you must pay the dental office during a visit depending on the service(s) you are coming in for.
Depending on your specific insurance plan, you may or may not have a copay.
Play Year Maximum
The total amount an insurance company will pay your dental office, on your behalf, during your insurance year. After this amount is paid, you must personally cover any further expenses incurred during the insurance year.
Pre-Treatment Estimate
If you want to see how much a dental procedure or treatment plan would cost you out of pocket, ask your dental office to submit a pre-treatment estimate.
This doesn’t guarantee payment by your insurance company, but it gives you a good idea of what they will cover and what you would have to pay for.
This list is a good place to start for insurance terminology. Of course, there’s lots more to learn.
For example, what’s the difference between a PPO, HMO, or fee-for-service plan you ask? Click here! Otherwise, we’ve got another great springboard of insurance terms for you here.
When in doubt, call your dental insurance company. They will give you the most accurate and up-to-date information on your specific plan.
You can also call your friendly neighborhood dental office to explain a few things. Don’t be bashful about asking for help! Not many people can say they’re experts in this area!
