Dental benefits coverage can resemble piecing together a puzzle. Knowing the common terms used can help you see the big picture.
This is the total dollar amount your dental plan will pay during a plan’s year. The final decision on the maximum payment amount is determined by your employer or the dental plan.
The annual maximum is typically $1,000 or $1,500. These figures have not changed much in the past 50 years.
These totals are applied to one person. Each of your family members will have a separate annual maximum and you’re responsible for the co-payments and any costs above the annual maximum.
“Assignment of Benefits”
This occurs when you authorize the dental plan to forward payment for a covered procedure directly to your dentist who treated you.
Your plan costs will be much less when the treatment cost is shared by the plan and those who are enrolled in it. There are different ways to share costs including deductibles, co-payments, frequency limitations, annual maximums, and the use of a fee schedule to calculate your benefit payments.
This is the out-of-pocket amount you must pay before your benefits plan will pay for any service you received. For example, if your deductible is $50, your plan will pay once you’ve paid $50 in related costs.
Your dental plan, like most, is based on a calendar year (January through December). You will pay the deductible amount once each year.
It could require more than one service or appointment to meet your entire deductible. Your plan will outline what services are applied to your deductible amount.
These are the dental services you receive that are not covered by your plan.
Your plan contains a list of conditions or circumstances that limit or exclude certain services from your coverage. Limitations determine how often a specific service is covered and are related to time or frequency (the number of procedures you’re allowed during a certain period).
For example, you could be allowed two teeth cleanings in a 12 months or one cleaning every six months.
“Least Expensive Alternative Treatment (LEAT)”
Your plan will only pay for the least expensive treatment if you have more than one option to treat the condition.
Your plan can exclude conditions that you had prior to enrolling in the plan. For example, if you were missing a tooth prior to your coverage effective date your tooth replacement treatment will not be covered.