Dental Insurance Glossary [A-C]

Access – The availability of dental care to a patient. This can be determined by location, transportation, type of dental services in the area, etc.

Accident - An event that is unforeseen, unexpected, and unintended.

Accidental Bodily Injury - Physical injury sustained as the result of an accident.

Accumulation Period - Period during which the insured incurs eligible dental expenses to satisfy a deductible.

Actively-At-Work - Most group dental insurance policies state that if an employee is not actively at work on the day the policy goes into effect, the coverage will not begin until the employee does return to work.

Actual Charge - The actual amount charged by a dentist for dental services rendered.

Actuary - Accredited insurance mathematician who calculates premium rates, reserves, and dividends and who prepares statistical studies and reports.

Acute Care - Skilled, medically necessary care provided by dental and nursing personnel in order to restore a person to good health.

Additional Drug Benefit List - Prescription drugs listed as commonly prescribed by dentists for patients' long-term use. Subject to review and change by the dental plan involved. Also called drug maintenance list.

Administrative Services Only (ASO) Agreement - Contract between an insurer (or its subsidiary) and a group employer, eligible group, trustee, or other party, in which the insurer provides certain administrative services. These services may include actuarial support, plan design, claims processing, data recovery and analysis, benefits communication, financial advice, dental care conversions, data preparation for governmental reports, and stop-loss coverage.

Adjusted Community Rating (ACR) - Community rating adjusted by factors specific to a particular group. Also known as factored rating.

Admissions/1,000 - The number of admissions for each 1,000 members of the dental plan.

Admits - The number of admissions to a hospital (including outpatient and inpatient facilities).

Adverse Selection - Tendency of those who are poorer-than-average dental risks to apply for, or maintain, insurance coverage.

Age Change - The date on which a person's age, for insurance purposes, changes. In most Life Insurance contracts this is the date midway between the insured's natural birth dates. Dental insurers frequently use the age of the previous birth date for rate determinations. On the date of age change, a person's age may change to that of the last birth date, the nearer birth date, or the next birth date, depending upon the way in which the rating structure has been established by that particular insurer.

Age/Sex Factor - Compares the age and sex risk of dental costs of one group relative to another. An age/sex factor above 1.00 indicates higher than average risk of dental costs due to that factor. Conversely, a factor below 1.00 indicates a lower than average risk. This measurement is used in underwriting.

Age/Sex Rates (ASR) - Separate rates are established for each grouping of age and sex categories. Preferred over single and family rating because the rates and premiums automatically reflect changes in the age and sex content of the group. Also sometimes called table rates.

Agent - Insurance company representative licensed by the state who solicits, negotiates, or effects insurance contracts and who provides services to the policyholder for the insurer.

Allied Health Personnel - Health personnel who perform duties, which would otherwise have to be performed by physicians, optometrists, dentists, podiatrists, nurses, and chiropractors. Also called paramedical personnel.

Allocated Benefits - Payments authorized for specific purposes with a maximum specified for each. In hospital policies, for instance, there may be scheduled benefits for X-rays, drugs, dressings, and other specified expenses.

Allowable Charge - The lesser of the actual charge, the customary charge and the prevailing charge. It is the amount on which Medicare will base its Part B payment.

Allowable Costs - Charges that qualify as covered expenses.

Ancillary Services - Dental care services that patients receive from providers other than primary care dentists.

Ancillary Benefits - Benefits for miscellaneous hospital charges.

Approved Charge - Amounts paid under Medicare as the maximum fee for a covered service.

Approved Dental Care Facility or Program - A facility or program that has been approved by a dental care plan as described in the contract.

Assignment of Benefits - A method where the person receiving the dental benefits assigns the payment of those benefits to a dentist or hospital.

Average Cost Per Claim - The total cost of administrative and/or dental services divided by the number of units of exposure such as costs divided by number of admissions, or cost divided by number of outpatient claims, etc.

Average Length of Stay (ALOS) - The total number of patient days divided by the number of admissions and discharges during a specified period of time. This gives the average number of days in the hospital for each person admitted.

Average Wholesale Price (AWP) - Under the Medicare catastrophic coverage act, payment for prescription drugs is limited to the lowest of the pharmacy's actual charge, the sum of the AWP for the drug plus an administrative allowance, or effective 1992, the 90th percentile of pharmacy charges.

Base Capitation - The total amount which covers the cost of dental care per person, minus any mental dental or substance abuse services, pharmacy, and administrative charges.

Basic Hospital Expense Insurance - Hospital coverage providing benefits for room, board and miscellaneous expenses for a specified number of days.

Benefit Levels - The maximum amount a person is entitled to receive for a particular service or services as spelled out in the contract with a dental plan or insurer.

Benefit Package - A description of what services the insurer or dental plan offers to those covered under the terms of a dental insurance contract.

Benefit Period - Defines the period during which a Medicare beneficiary is eligible for Part A benefits. A benefit period is 90 days, which begins the day the patient is admitted to a hospital and ends when the individual has not been hospitalized for a period of 60 consecutive days.

Billed Claims - The amounts submitted by a dental care provider for services provided to a covered individual.

Binding Receipt - A receipt given for the payment that accompanies an application for insurance. If the policy is approved, the payment "binds" the company to make the policy effective from the date of receipt.

Board-certified - A designation that a dentist has successfully completed an approved educational program and evaluation process by the American Board of Dental Specialties (ABMS) which includes an examination designed to assess the knowledge, skills, and experience required to provide quality patient care in a given specialty.

Board Eligible - A professional person or dentist who is eligible to take a specialty examination.

Broker - Person licensed by the state that places business with several insurers; the broker, although paid a commission by the insurer, represents the buyer rather than the insurance company.

COBRA - See Consolidated Omnibus Budget Reconciliation Act of 1986.

Capitation - A method of paying for dental services on a per-person rather than a per-procedure basis. Under capitation, an HMO pays a doctor a fixed amount each month to take care of HMO members, regardless of how much or how little care each member needs.

Carrier - Usually a commercial insurer contracted by the Department of Health and Human Services to process Part B claims payments.

Carry Over Provision - In major dental policies, allowing an insured who has submitted no claims during the year to apply any dental expenses incurred in the last three months of the year toward the new calendar year's deductible.

Case Manager - A person, usually an experienced professional, who coordinates the services necessary under the case management approach.

Catastrophe Policy - This is an older name for Major Dental.

Certificate of Authority (COA) - Issued by the state, it licenses the operation of an HMO.

Certificate of Insurance - Document that summarizes the provisions and benefits of an insurance contract. May be distributed in booklet form.

Chemical Dependency Services - The services required in the treatment and diagnosis of chemical dependency, alcoholism, and drug dependency.

Chemical Equivalents - Drugs that contain identical amounts of the same ingredients.

Closed Panel - A situation where covered insureds must select one primary care dentist. That dentist is the only one allowed to refer the patient to other dental care providers within the plan. Also called Closed Panel or Gatekeeper model.

Coinsurance - The amount you are required to pay for dental care in a fee-for-service plan or preferred provider organization (PPO) after you have met your deductible. It is usually expressed as a percentage of billed charges. For example, if the insurance company pays 80 percent of the claim, you pay 20 percent.

Commercial Policy - In Health Insurance, this term originally applied to policy forms intended for sale to individuals in commerce, as contrasted with industrial workers. Currently the term is loosely used to mean all policies that do not guarantee renewability.

Community Rating - Under this rating system, the charge for insurance to all insureds depends on the dental and hospital costs in the community or area to be covered. Individual characteristics of the insureds are not considered at all.

Composite Rate - One rate for all members of the group regardless of their status as single or members of a family.

Comprehensive Major Dental - A plan of insurance which has a low deductible, high maximum benefits, and a coinsurance feature. It is a combination of basic coverage and major dental coverage which has virtually replaced separate hospital, surgical and dental policies with each having its own deductible requirements. Also see Major Dental Insurance.

Conditional Binding Receipt - It provides that if a premium accompanies an application, the coverage will be in force from the date of application or dental examination, if any, whichever is later, provided the insurer would have issued the coverage on the basis of the facts revealed on the application, dental examination and other usual sources of underwriting information. A Life and Health Insurance policy without a conditional binding receipt is not effective until it is delivered to the insured and the premium is paid.

Conditionally Renewable - A contract that provides that the insured may renew it to a stated date or an advanced age, subject to the right of the insurer to decline renewal only under conditions stated in the contract.

Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1986 - Legislation providing for a continuation of group health care benefits under the group plan for a period of time when benefits would otherwise terminate. Continuation rights apply to enrolled persons and their dependents. Coverage may be continued for up to 18 months if the insured person terminates employment or is no longer eligible. Coverage may be continued for up to 36 months in nearly all other cases, such as loss of dependent eligibility because of death of the enrolled person, divorce, or attainment of the limiting age.

Continuation - Allows terminated employees to continue their group dental insurance coverage under certain conditions.

Consumer Price Index (CPI) - A measure of the average change in prices over time in a fixed group of goods and services. In this report, all references to the CPI relate to the CPI for Urban Wage Earners and Clerical Workers (CPI-W).

Contract Year - This period runs from the effective date to the expiration date of the contract.

Conversion Privilege - Right given to an insured person under a group insurance contract to change coverage, without evidence of dental insurability, to an individual policy upon termination of the group coverage. The conditions under which conversion can be made are defined in the master policy.

Coordination of Benefits (COB) - Method of integrating benefits payable under more than one dental insurance plan so that the insured's benefits from all sources do not exceed 100 percent of allowable dental expenses or eliminate incentives to contain costs.

Co-payment - A specific charge you pay for a specific dental service. For example, you may pay $10 for an office visit or $5 for a prescription and the dental plan covers the rest of the dental charges.

Corridor Deductible - A Major Dental deductible that provides for a deductible, or "corridor," after the full payment of basic hospital and dental expenses up to a stated amount. In the event of further expenses, payment is on the basis of participation or coinsurance, such as 80%-20% or 85%-15%, and the deductible is that portion paid by the insured.

Cost Contract - An agreement between a provider and the Health Care Financing Administration to provide dental services to covered persons based on reasonable costs for service.

Cost Sharing - A situation where covered persons pay a portion of the dental costs such as deductibles, coinsurance, or copayment amounts.

Covered Expenses - Dental care expenses incurred by an insured or covered person that qualify for reimbursement under the terms of a policy contract.

Covered Person - A person who pays premiums into the contract for the benefits provided and who also meets eligibility requirements.

Continue for Dental Glossary D-W

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