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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vs. secondary coverage, but it may be superseded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.
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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."
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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.
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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.
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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."
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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.
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Deductible:
The amount you pay for treatment
before certain benefits are paid. In most programs,
deductibles must be met each year.
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Dual
choice: An option
that allows you to select from two or more types
of dental programs. Also called "dual option."
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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.
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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.
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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
prepaid plans work. The fee-for-service method
is the traditional way of delivering dental benefits.
DeltaPremier
and DeltaPreferred
Option are fee-for-service programs.
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Guaranteed
copayments: A feature
of most Delta fee-for-service and prepaid dental
plans that protects you from unexpected expenses.
For example, in a DeltaPremier 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.
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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.
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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).
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Network:
Dentists who have
contractually agreed to provide treatment according
to administrative guidelines for a certain program.
Sometimes known as a "panel."
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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.
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Notice
of payment: The statement
you are mailed detailing how your claim payment
was calculated. It is sometimes called an Explanation
of Benefits.
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Out-of-pocket
costs: Any amount
you are responsible for paying, such as copayments,
deductibles and costs above your annual maximum.
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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. DeltaPreferred
Option is a PPO program.
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Point
of service: The DeltaCare
point of service program combines prepaid
and fee-for-service benefits. As with a prepaid
dental plan, you enroll with a network dentist
and receive treatment from that dentist. However,
you are free to choose an out-of-network dentist
at any time, with benefits paid on a fee-for-service
basis.
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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.
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Pre-existing condition: An example
of a pre-existing condition is a tooth that was
extracted prior to an enrollee receiving coverage.
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