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Glossary of dental benefit terms
Birthday rule: When a dependent child's parents both have dental coverage, 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. The birthday rule is the most common rule for determining primary vs. secondary coverage, but it may be superseded by a court order such as a divorce agreement. Cafeteria plan: A benefit program in which you are given a certain amount (in dollars or points) to be used toward your choice of benefits. You then select (cafeteria style) which benefits you would like from a list provided by your employer. Also known as "flexible benefits." Capitation: A dental benefit program in which a network dentist agrees to provide all or most covered dental services to those who enroll with his/her office. The carrier pays the network dentist per capita (for each enrolled patient) rather than per service. See "health maintenance organization." 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. COB: Abbreviation of coordination of benefits. When you are covered by more than one benefit plan, the two benefits are coordinated so that no more than 100 percent of the total covered expenses is paid. See "non-duplication of benefits" and "birthday rule." Copayment: Your share of the cost of a given service. It may be a percentage of the dentist's approved fee or a fixed dollar amount. Deductible: The amount you pay for treatment before certain benefits are paid. In most programs, deductibles must be met each year. Dual choice: An option that allows you to select from two or more types of dental programs. Also called "dual option." Dual coverage: When you have coverage under more than one benefit program. The primary and secondary carriers coordinate the two programs, so that the primary carrier pays its portion first and the secondary carrier usually pays the remainder. See "Non-duplication of benefits" and "birthday rule." More information on dual coverage. Enrollee: This word applies to the person who is covered under a Delta program. An enrollee may also be referred to as a subscriber or patient. Fee-for-service: A program design in which the dentist is paid for each service, rather than a fixed amount per patient, which is how many HMOs work. The fee-for-service method is the traditional way of delivering dental benefits. Delta Dental Premier and Delta Dental PPO are fee-for-service programs. Fee listing/filed fees: Every Delta dentist submits a list of fees for approval by Delta. If those fees are acceptable and meet all guidelines, they are used to calculate Delta Dental's payment and the patient's payment. 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. HMO: The abbreviation for health maintenance organization, a benefit program in which you receive all or most treatment through the dental office where you are enrolled. The dentist receives a single monthly payment from the benefits carrier for each enrolled patient, no matter how many services that patient receives. DeltaCare USA is a dental HMO 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. Maximum: A dollar limit that is applied to benefit payments. Some programs have no maximum. Some maximums apply to the lifetime of the benefit program; others apply to a particular period of time (calendar year, benefit year, etc.) or particular services (such as separate maximum for orthodontic benefits). Network: Dentists who have contractually agreed to provide treatment according to administrative guidelines for a certain program. Sometimes known as a "panel." Non-duplication of benefits: If you are covered by two programs (dual coverage), non-duplication of benefits is a term used to describe one of the ways the secondary carrier may calculate its portion of the payment. The secondary carrier calculates what it would have paid if it were the primary plan and subtracts what the other plan paid. For example, if the primary carrier paid 80 percent, and the secondary carrier normally covers 80 percent as well, the secondary carrier would not make any additional payment. If the primary carrier paid 50 percent, however, the secondary carrier would pay up to 30 percent. 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 you are responsible for paying, such as copayments, deductibles and costs above your annual maximum. PPO: The abbreviation for preferred provider organization. A fee-for-service program that allows you to choose any dentist but provides financial incentives to choose dentists who are part of the PPO network. Delta Dental PPO is a PPO program. Predetermination: Gives an estimate of how much of a proposed treatment plan will be covered under your dental program. A predetermination lets you figure your costs before you receive major treatment. Any enrollee can ask the dental office to submit a predetermination request. 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.
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