Common Terms Dental Insurance Explained

Preventive care are the steps we take to keep our bodies healthy. Preventive dental care helps us maintain the health of our mouths. This allows us to avoid tooth decay, tooth loss, and other harmful issues. Bi-annual dental visits are encouraged because they can prevent problems in the mouth from occurring. When your dentist catches cavities and decay early on, they can stop them from getting worse. Preventive care reduces your chance of needing complex dental work down the road. It also helps your dentist see any changes in your mouth when you return six months later for your next appointment! Did you know your dental benefits are shaped around preventive care? When we understand what preventive care is, we can better understand how to put our dental benefits to use.

Better understand your dental benefits by getting familiar with how they work:

Dental Coverage and Preventive Care

Because we believe in the importance of dental care, Delta Dental plans usually cover 100 percent of routine preventive and diagnostic care. This includes dental care procedures like cleanings, exams, and x-rays.

If your dentist comes across tooth decay or signs of a cavity, fillings, root canals, and tooth extractions are usually covered at 80 percent. That means Delta Dental will pay the majority of the cost, leaving you with 20 percent to pay. Crowns, bridges, implants and other major procedures are usually covered at 50 percent, meaning you’ll split the cost evenly. Keeping a healthy mouth is easier and saves you money when you have dental benefits to rely on.

Be aware that a deductible — the amount you pay before your dental insurance kicks in — may apply to these services.

What is a Dental Claim Form?

A claim is created when you get a dental procedure done. It’s a document that outlines the procedures that were performed at the dentist. This document is sent to your insurance provider, Delta Dental. Our team members review the claim against your oral health history to ensure the procedure was right for your needs. They will also make sure your benefits were applied correctly.

Our dental coverage claim audit process protects members from fraudulent billing practices. Claims prevent incorrect billing or coverage applications. For example, if x-rays from your dentist don’t match the work listed on the claim, we can request clinical notes or a narrative for verification. Claims help us keep our members healthy and safe.

What is a Deductible?

The amount of money a member agrees to pay before Delta Dental starts to pick up the tab is called your “deductible.” You must pay for your dental care until your plan’s deductible is met. But, you only have to meet your deductible once in a plan year. Deductibles don’t apply to regular exams, x-rays, and cleanings! Preventive care services like cleanings are covered 100 percent right off the bat, even if your deductible hasn’t been met yet. Sign into your member portal or review your member ID card to see what your plan’s deductible is.

What is a Copay? What is Coinsurance?

Coinsurance and copays are how you share the cost of dental procedures after you’ve met your deductible. A copay is a fixed dollar amount, like $20. Coinsurance, on the other hand, is usually written as a percentage.

With a copay, you’ll always pay the fixed amount (say, $20) no matter how much the total cost from the dentist was. As a percent, coinsurance changes depending on the total cost from the dentist.

Not all dental plans use copays, while others may use both copays and coinsurance. Consult your specific plan to see if you have a copay and what your copay is. Some services like preventive care appointments may be covered at no out-of-pocket cost to you. 

What is an Annual Maximum?

This refers to the maximum amount of money your plan will pay for dental services in your plan year. If a member’s plan is based on the calendar year, then the time frame for their annual maximum is from January to December. If your annual maximum is reached in August, you will have to pay for dental procedures without sharing the cost with Delta Dental until your plan year starts over the following January.

What is a Dental Benefits Premium?

This is the fee paid for your dental plan, which is usually a monthly charge. If your benefits are given to you through your employer, they pay either part of or all of the dental insurance premium.

Broaden your understanding of the dental benefits basics with Dental Insurance 101.

*Updated 2019