Glossary of Dental Plan Terms

For additional information, please refer to your policy.

Actual charge

The amount a provider bills a patient for services or supplies.

Annual deductible

The fixed dollar amount you pay each calendar year before your dental plan benefits begin.

Annual maximum

The maximum dollar amount your plan pays for services during a calendar or plan year.

Calendar Year

A 12-month period beginning January 1 and ending December 31.

COBRA

The Consolidated Omnibus Budget Reconciliation Act of 1986 is a federal law that lets covered employees and their eligible dependents pay for continued dental plan benefits if their plan ends because of a qualifying event such as leaving a job or getting a divorce.

Coinsurance

The sharing of expenses between an insurance company and an insured for covered dental benefits and services after the deductible is met. The insured is responsible for the remaining percentage of the allowance, if any, and for all non-covered services; and charges in excess of any benefit maximum. Let’s say your plan pays 80% coinsurance for a dental service. If the service costs $150, you pay 20% ($30) and your dental plan pays 80% ($120) after your deductible has been met.

Coordination of benefits

You may have another dental plan that provides the same or similar benefits as your BlueDental plan. If you have another dental plan, we’ll work with that plan to determine which plan is the primary payer and which is secondary. Other coverage includes group-sponsored insurance, non-group sponsored insurance, other group benefit plans, Medicare or other government benefits, and dental benefits that may be included in your automobile insurance.

If you have more than one dental plan, please review the Coordination of Dental Benefits Section in your dental policy documents

Copayment

The fixed dollar amount you pay for covered dental services.

Deductible

The set dollar amount you must pay for covered services each calendar year before reimbursement for dental benefits begins. Let’s say you have a $50 deductible for treatments. If the treatment charges are $120, you pay $50 to meet the deductible and your plan pays the benefit amount for covered services.

Eligible charge

The maximum amount that a dentist charges based on an agreement between the provider and Florida Blue when using an in-network provider and subject to conditions and requirements which make the service eligible for reimbursement. Let’s say your dentist charges $100 for a treatment (the actual charge), but Florida Blue and the provider agrees to a $75 eligible charge for the treatment. The dentist bills you $75, you pay a portion of it (your copayment or coinsurance), and we pay the rest.

If an out-of-network dentist charges more than the allowed amount, you may have to pay the difference.

Explanation of Benefits (EOB)

A statement that explains how we processed a claim based on the services performed, the actual charge, and any adjustments to the actual charge, our eligible charge, the amount we paid, and the amount you may owe. You can view a detailed explanation of EOBs on our website.

Florida Blue member account

A secure area on Florida Blue’s website that lets you manage your Florida Blue medical and dental plan benefits. Your Florida Blue member account gives you access to information about your plan and claims, forms, and other tools.

Health care reform

One of the primary goals of the comprehensive health care reform law enacted in March 2010 (sometimes known as the Affordable Care Act, ACA or PPACA), was to make affordable health insurance available to more people. The law provides consumers with subsidies (“premium tax credits”) that lower costs for households with incomes between 100% and 400% of the federal poverty level.

Dental Health Maintenance Organization (DHMO)

Dental Health Maintenance Organization (DHMO) plans are a prepaid option that offer members low cost, basic dental benefits. When you visit a dentist in a network, exams, cleanings and X-rays are usually covered at 100%. If you have minor or major services, you pay a copayment. If you visit any specialist or a dentist outside a network, you pay 100%. DHMOs typically don’t have deductibles, waiting periods or an annual maximum. Members must choose a Primary Care Dentist.

Individual plans

Health plans for people who don’t have health insurance through a job. You typically pay the entire amount of the monthly premiums.

Maximum allowance

The maximum payment allowed by the insurance company for applicable covered services and supplies provided by a dentist.

Maximum Rollover

A benefit included in many BlueDental PPO plans that allows you to save unused benefit dollars in a given year and use them in future years. You can plan and schedule major services in advance or just have additional benefit dollars available to use if you need to have an unexpected procedure or have an emergency. With Maximum Rollover, your benefit dollars can add up over time. You can easily check to see how many rollover dollars you may have when you log into your Florida Blue member account. Check your policy to see if it includes Maximum Rollover.

Network

A provider network is a group of dentists and other oral health professionals who have a contract with Florida Blue. Florida Blue negotiates payment rates with participating providers to provide services to its members.

Non-participating provider

Non-participating providers are dentists that don’t have a contract with Florida Blue to charge set rates. Getting treated by non-participating providers almost always costs more than getting care from participating providers.

Oral Health for Overall Health

This program provides eligible PPO plan members who have qualifying medical conditions with enhanced dental benefits that can help them improve their oral health and manage certain medical conditions. Learn more about Oral Health for Overall Health. Check your policy to see if you’re eligible.

Out-of-pocket maximum

The out-of-pocket maximum is the maximum dollar amount you’ll pay toward covered services during a calendar year if you visit an in-network, participating provider. Once the out-of-pocket maximum is met, you’re no longer responsible for a deductible (if applicable), coinsurance or copayment amounts, unless otherwise noted.

Participating provider

A dentist or specialist who has a contract with Florida Blue to charge set rates for services or products. Seeing these providers almost always costs less than getting care from non-participating providers.

Premium

The amount you pay monthly for your dental policy. If you don’t pay premiums on or before the due date, your coverage may be terminated.

Prepaid Dental Plan

A Prepaid dental plan works like a DHMO. The insurance provider pays the contracted dentist a fixed amount every month for every member. The dentist receives a monthly payment whether or not the member uses the dental insurance.

Primary Care Dentist

The participating general dentist within a plan’s network whom you have selected to handle your dental care.

Prior Authorization or Predetermination

An approval process to determine an insured’s eligibility and the amount payable under the plan before services are rendered.

Preferred Provider Organization (PPO)

Dental PPO networks are usually larger than dental HMO networks. They typically have a deductible that must be satisfied before payment of benefits can begin and an annual maximum amount that the insurance company will pay. You can see a dentist or specialist in- or out-of-network, but your out-of-pocket costs will be lower when you see a dentist or specialist in the network.

Preventive care

Regularly scheduled dental cleanings, exams and X-rays that can help prevent and detect conditions early to ensure successful treatment. Learn more about preventive care.

Qualifying event

A life occurrence that changes a former employee’s eligibility status under a group health plan. The term is used to determine COBRA eligibility. Qualifying events include termination of employment or a change in marital status.

Special Enrollment Period

The period of time outside the open enrollment period when you can sign up for dental insurance. You qualify for a special enrollment period if you’ve had a certain life event, such as losing dental coverage, moving, getting married, having a baby or adopting a child.

Service limitations

A service limitation restricts a covered service, such as how often you can receive a service, an age restriction or another limitation. You can find more information about service limitations and exclusions and other coverage details in your policy.

Waiting period

Some dental plans require you to wait for a period of time before receiving certain services. You’re responsible for 100% of charges for any service subject to a waiting period if you don’t meet the required waiting period.