Deductible: Like most home, auto and health insurance plans, a dental plan may include a fixed amount the member is responsible to pay prior to your plan paying benefits. Typically, deductibles apply to Basic and Major Restorative care and not Diagnostic or Preventative care.
Lifetime Deductible: In some plans, the deductible for basic and major restorative procedures is only paid once in a lifetime per enrolled individual, up to a maximum of three individuals per family. Once this provision is met, you will no longer be subject to a deductible.
Maximums: The maximum benefit amount a plan will provide for certain services during a benefit period, typically a calendar year. Once this cap is reached, the patient is responsible for all Basic and Major Restorative services for the remainder of the period. Typically, Preventative and Diagnostic treatments are not subject to maximums.
Coinsurance: Most dental plans only pay a percentage of the treatment cost once a member has reached their deductible. Coinsurance refers to the part the patient pays once they have reached their deductible.
Copayments: Refers to the fixed dollar amount a member pays at time of service for specific services. When you enroll, the insurer will provide a list of covered treatments along with associated copayment amounts. These can be as little as $15 per treatment visit.
Lifetime Maximums: The total cumulative benefit amount a plan will pay for a specific dental service of an individual enrollee’s dental care for the life of the plan. Orthodontics typically fall into this service category.
Pre-Treatment Estimates: For any treatment, you can ask your dentist to submit a pre-treatment estimate to your insurer. This is good practice for costly or expensive treatments so you know how much you will be required to pay out-of-pocket.
Closed Network Plan: With Network designed plans, coverage as outlined in your policy is limited to a pre-selected or pre-assigned network of dentists. To receive full benefits, you must visit a dentist within your network. Partial benefits are often provided for out-of-network providers.
Reimbursement Levels: A fee-for-service plan will offer certain categories of coverage, each receiving a specific percentage of coverage. For example:
- Preventative and Diagnostic procedures are typically covered at 100%. This gives policyholders incentives for getting cleanings and checkups which could reduce the likelihood of more costly procedures in the future.
- Basic Restorative typically include fillings, extractions, periodontal maintenance, denture repair, among others. Coverage percentages can range from 50%-80%.
- Major Restorative will cover from 25% - 60% of procedures such as Crowns, Implants, Root canals, Dentures, Treatment of gum disease and Onlays
