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Glossary of Dental Plan Terms

For additional information, please refer to your plan documents.

Actual charge

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

Annual copayment maximum

The maximum deductible and copayment amounts you pay for most covered services in one calendar year.

Annual deductible

The fixed dollar amount you pay each calendar year before your health plan will pay for certain services.

Calendar year maximum

The maximum dollar amount that we’ll pay for services during a calendar year. See Calendar Year Rollover.

Calendar Year Rollover

Rollover is a portion of unused calendar year maximum that may be carried over to the next year, increasing the dollar amount available to pay for covered services during that subsequent year. With Calendar Year Rollover, your benefits can add up over time. Check your Dental Guide to Benefits to see if you’re eligible. My Account makes it easy to see how many rollover dollars you have.

COBRA

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

Coinsurance

The percentage you pay out of pocket for medical services and products that are benefits of your health plan. Let’s say your plan has a 20% coinsurance for a dental service. If the service costs $150, you’ll pay 20% ($30) and your health plan pays the remaining 80% ($120).

Coordination of benefits

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

If you have more than one dental plan, follow these instructions.

Copayment

The fixed dollar amount you pay out of pocket for medical services and products that are benefits of your health plan. Let’s say your health plan has a $20 copayment for dental visits. If a visit costs $100, you’ll pay $20 and your health plan pays the remaining $80.

Deductible

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

Eligible charge

The maximum amount that a dentist charges based on an agreement between the provider and HMSA. Let’s say your doctor charges $100 for a treatment (the actual charge), but HMSA negotiates a $75 eligible charge for the treatment. The doctor bills you $75, you pay a portion of it (your copayment or coinsurance), and we pay the rest.

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. A dental EOB is similar to a Report to Member that you may receive if you have an HMSA health plan.

Health care reform

Called the Affordable Care Act (ACA), this law to reform the nation’s health care system took effect in March 2010, to help more people get affordable, quality health care.

Health Maintenance Organization (HMO)

Dental HMO plans are a prepaid option. When you visit a dentist in the 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 a dentist or specialist outside the network, you pay 100%. HMOs typically don’t have deductibles, waiting periods, or an annual maximum.

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 allowable fee

The maximum amount that HMSA will pay for covered services and supplies.

My Account

A secure area on HMSA’s website that lets you manage your HMSA plan benefits. My Account gives you access to information about your plan and claims, HMSA forms, and other tools.

Network

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

Nonparticipating provider

A provider who doesn’t have a contract with HMSA. Nonparticipating providers includes doctors and other health care providers, pharmacies, or labs that don’t have a contract with HMSA to charge set rates. Using these providers almost always costs more than using participating providers.

Oral Health for Total Health

This program provides eligible members with enhanced dental benefits to help them improve their oral health and improve and manage certain medical conditions. Learn more about Oral Health for Total Health.

Out-of-pocket maximum

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

Participating provider

A dentist or specialist who has a contract with HMSA to charge set rates for services or products. Seeing these providers is almost always costs less than using nonparticipating providers.

Payment determination criteria

Hawaii law requires that HMSA use specific criteria to determine if a service or supply is medically necessary.

Premium

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

Prior Authorization

Prior authorization is an approval process to make sure that certain treatments, procedures, or devices meet payment determination criteria before the service is rendered. If you’re under the care of an HMSA participating dental or contracting provider, he or she will get approval for you. Learn more here.

Preferred Provider Option (PPO)

Dental PPO networks are typically larger than dental HMO networks. PPOs typically have an annual maximum and a deductible that must be satisfied before your copayment or coinsurance applies. You don’t need a referral to see a specialist, but your out-of-pocket costs will be lower when you see a specialist in the network. Preventive care is usually covered at 100% while deductibles and copayments and coinsurance apply to minor and major services and treatments.

Pretreatment Estimate

When you need minor or major dental treatment, a pretreatment estimate is a good way to understand the costs and HMSA coverage. It’s especially recommended for complex procedures such as crowns, root canals, bridges, dentures, and implants.

Preventive care

Regularly scheduled dental cleanings, exams, and X-rays 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.

Service limit

A service limit restricts a covered service in some way, such as dollar amount, how often you can receive a service, an age restriction, or another limitation. See your Dental Guide to Benefits for more information.

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 that subject to a waiting period if you don’t meet the required waiting period.