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Frequently used dental insurance terms: Abutment: The teeth on either side of a missing tooth. Abutments are the part of the bridge used to support the replacement of the missing teeth (pontics). Amalgam: A silver/mercury mixture, which is used for fillings. Anniversary year: Begins on the day of the month that the patients' insurance became effective. Assignment of benefits: A clause in the policy that allows the insured person to direct the payment by the carrier to the dentist. The insured person does this by signing the assignment box on the claim form, or by signing a signature on file form. Basic care: Includes root canal therapy, extractions, and fillings (usually covered at 80%). Benefit year: Usually begins on the month of the year that the employer purchased the plan. Birthday rule: When a child is covered under both parent's plans, the plan of the parent who's birthday (month and day, not year) falls earlier in the calendar year is billed first. (In cases of divorced or separated parents there are other factors that must be considered.) Capitation plan: A plan where the dentist is contracted with the administrator to provide dental services to persons covered under the program in return for payment on a per-capita basis (per head). Trojan classifies these plans as Managed Care. Carryover: If the deductible was paid last year (usually the last quarter, Oct., Nov. or Dec.) the next year (or quarter, Jan., Feb. and March) they do not have to pay the deductible again. Closed Panel: This type of plan allows covered patients to receive care only from dentists who have signed a contract of participation with the third party. The third party contracts with a certain percentage of dentists within a particular geographic area. There are two types of closed panel plans: PPO's and EPO's. Coinsurance: A specified percentage of the cost of treatment the insured is required to pay for all covered medical expenses remaining after the deductible has been met. Composite filling: Tooth colored filling. Insurance companies usually only allow them on the front teeth (anterior teeth). When composites are done on the back teeth (posterior teeth) the insurance company usually pays them as an amalgam. Composites are also known as resin fillings. Copay: A fixed dollar amount, you pay at the time services are rendered. Typical copays are for office visits, prescriptions, or hospitalizations. Deciduous teeth: Primary Teeth. Deductible: The portion of your health care that you pay before insurance starts covering it. Typically, the higher the deductible, the lower the premiums. Most insurance plans have a deductible of $50 to $100, pay only a specified percentage for each type of treatment, and have a yearly maximum amount of funds available for dental care. Dental implants: Either surgical placement or restoration. Dental Service Corporations: not-for-profit organizations to negotiate and administer contracts for dental care to individuals or specific groups of patients. Dentin: The bone-like (calcium) part of a tooth below the enamel. DMO (Dental Maintenance Organization): A legal entity that accepts the responsibility of providing services at a fixed price. The enrollees in these plans must have dental care provided through designated doctors. Trojan classifies these plans as Managed Care. Enamel: The hard ceramic part, which covers the exposed part of a tooth. Endodontics: Treatment of root canals and removal of tooth nerves. EPO (Exclusive Provider Organization): Patients receive dental care only from participating dentists. Although there may be some exceptions for emergency and out-of-area care, if a patient decides to see a dentist, who is not listed on the EPO panel, charges for service will not be covered by the plan. Because participating dentists are required to offer substantial fee reductions, many dentists elect not to participate in EPO-type plans. Under some benefits plans, participating dentists may be salaried employees of the EPO. An EPO contracts with a limited number of practitioners within a geographic area. The EPO also may limit the amount of services that a patient can receive in a given calendar year. Fluoride: A chemical solution or gel, which you put on your teeth. The fluoride hardens your teeth and prevents tooth decay (in dentistry). Gingivitis: The inflammation of your gums caused by improper brushing. The first sign of periodontal (gum) disease. HMO (Health Maintenance Organizations): They offer members an array of health benefits, usually including preventive care -- for a set monthly premium. Indemnity: Fee-for-service, allows you to go to any hospital or doctor. You submit a claim and pay the invoice (to be reimbursed later) or authorize the hospital or doctor to collect their fees directly from your insurance company. LEAT: Least Expensive Alternative Treatment approach. Major care: Includes crowns (caps), permanent bridgework, and full and partial dentures, as well as periodontal (gum) care. (These items are often covered at 50%). Open Panel: This type of dental benefits plan allows covered patients to receive care from any dentist and allows any dentist to participate. Any dentist may accept or refuse to treat patients enrolled in the plan. Open panel plans often are described as freedom of choice plans. Oral surgery: Tooth removal (not including bony impaction) and minor surgical procedures such as tissue biopsy and drainage of minor oral infections. Orthodontics: Treatment including retainers, braces and/or diagnostic materials. Periodontics: Treatment of uncomplicated periodontal disease including scaling, root planning and management of acute infections or lesions. PPO (Preferred Provider Organization): This type of plans allows a particular group of patients to receive dental care from a defined panel of dentists. The participating dentist agrees to charge less than usual fees to this specific patient base, providing savings for the plan purchaser. If the patient chooses to see a dentist who is not designated as a "preferred provider," that patient may be required to pay a greater share of the fee-for-service. Most PPO plans cover preventive care, cleanings, check-ups, protective dental sealants, x-rays, and fluoride treatment at 80-100%. Preventive care: Includes regular checkups and cleanings, it is the key to maintaining oral health. Prosthodontics: Repair and/or relining or reseating of existing dentures and bridges. Pulp: The soft inner structure of a tooth, consisting of nerves and blood vessels Restorative care: Amalgam and composite resin fillings and stainless steel crowns on primary teeth. Yearly maximum: Many insurance companies have a yearly maximum of a $1000. Dental insurance, usually, is not cumulative, so if you don't use it, you lose it.
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