Dental benefits can:
- Make dental care more affordable. By focusing on preventive services, your dentist can help catch problems early before they are more costly to repair.
- Make going to the dentist simple. When you stay in-network, the dentist files claims on your behalf, and Delta Dental will pay a portion of the bill.
- Provide access to dental expertise. Dental benefit carriers partner with dentists to make sure claims are handled correctly, and often provide resources and tools dedicated to helping you get the most out of your dental benefits.
Dental benefits can’t:
- Cover the full cost of dental care. While most dental benefit plans cover preventive services at 100 percent, they usually cover other services at lower percentage rates. Still, dental benefits do help you save money, especially if you use a network dentist.
Reviewing common terms can help you better understand your dental benefits statements and dental visits. Here are some terms you will see often:
Explanation of Benefits (EOB)
An EOB is a detailed statement of a processed claim sent to the enrollee and participating dentist. It shows procedures, date(s) of service, processing policies, Delta Dental's payment and the amount (if any) that the enrollee owes to the dental provider. Learn more and watch a video here.
Deductibles
Many benefit plans have a deductible. During your benefit year, you will have to pay a portion of your dental bill before your benefits pay toward it. Some benefit plans waive deductibles for preventive and diagnostic services; be sure to check your benefits before your dental visit to see if this applies to you.
Maximums
An annual maximum is the maximum dollar amount your plan will pay toward the cost of dental care within a specific period, usually a calendar year. A lifetime maximum is the amount a plan will pay over the course of a lifetime. This may apply to an individual or a family and usually applies to specific treatments such as orthodontia.
If your dental care costs exceed your annual or lifetime maximum, you are responsible for paying your dentist all costs above it.
Balance billing
This is the practice of billing a patient for the difference between what the dentist charges and the agreed-upon charge established by Delta Dental. In-network dentists cannot balance bill patients.
Benefit levels
Dental treatments are grouped into levels. The percentage covered by your dental plan often varies by benefit level. Most plans including the following benefit levels:
- Preventive services: includes exams, cleanings, X-rays and fluoride treatments.
- Basic services: includes procedures such as fillings, root canals, periodontal (gum) treatment and simple tooth extractions.
- Major services: includes procedures such as crowns, dentures and implants.
- Emergency services: dental services that are required immediately to avoid jeopardizing the patient’s health, or to relieve pain, swelling or bleeding.
- Orthodontic services: treatment and procedures used to correct misaligned or crooked teeth. These may include braces, retainers and other orthodontic appliances.
Copayments and coinsurance
A copayment (copay) is a set dollar amount you are required to pay your dentist for a service. Coinsurance is a fixed percentage of a dental treatment cost that you share with your dental plan. For example, Delta Dental may pay 80 percent of a given service, while you are responsible for 20 percent. Coinsurance kicks in after you meet your deductible.
A member usually has a copayment or coinsurance, but not both.
Waiting period
Some dental plans have waiting periods for certain treatments. This means there is a period of time after your plan starts that you must wait before you can use benefits for that treatment.
Pre-treatment estimate
A pre-treatment estimate is usually submitted by a dentist for Delta Dental to review and provide an estimate of benefits before treatment starts. Pre-treatment estimates can help you budget for dental procedures. They can also help you and your dentist decide how to proceed with treatment.
Coordination of benefits
Coordination of benefits is a procedure for paying health care expenses when people are covered by more than one dental plan. The goal of coordinating benefits is to make sure the cost of the dental procedure is covered within the scope of the plans, without exceeding the amount of the actual bill.
If you or your dependent are covered by two or more dental plans, the coverage will be coordinated in accordance with the coordination of benefit rules set forth in your policies.