We know health care can be complicated. So we’ve provided a list of commonly used terms and definitions to help you navigate your care and coverage.
An aggregate deductible, also referred to as an “umbrella” deductible, is a way to calculate deductibles or out-of-pocket maximums for family coverage. Once a member or any combination of that person’s family members has met their plan’s deductible, benefits begin for the entire family. Similarly, once a member or any combination of family members has met their plan’s out-of-pocket maximum, no further member liability will apply for some or all covered services for the entire family. Not all services may be subject to the deductible and/or out-of-pocket maximum.
Balance billing is a type of dental care billing that occurs when a provider bills a member for the difference between an out-of-network provider’s charges and the amount paid by a member’s benefit plan. This situation happens when a provider is neither contracted nor a participant in a member’s provider network.
Coinsurance is a percentage of charges that you must pay when you receive a covered service as described in the “What You Pay” section of your Evidence of Coverage.
A copay is the defined dollar amount that you must pay when you receive a covered service as described
in the “What You Pay” section of your Evidence of Coverage.
A deductible is the amount you must pay in a calendar year for certain services before we will cover those services at the copayment or coinsurance level in that calendar year. Deductible amounts include the annual deductible take-over amount as described under “Deductible” in the “What You Pay” section of your Evidence of Coverage.
An embedded deductible is a way to calculate deductibles or out-of-pocket maximums for family coverage. Once a member has met his or her plan’s individual deductible, benefits begin for that individual. Meanwhile, the rest of the family must continue satisfying their deductible until they reach the family deductible level. Once the family deductible is satisfied, benefits begin for the rest of the family. Similarly, once a member has met his or her plan’s individual out-of-pocket maximum, no further member liability will apply for some or all covered services for that individual. Meanwhile, the rest of the family must continue satisfying their out-of-pocket maximum until they reach the family out-of-pocket maximum level. Once the family out-of-pocket maximum is satisfied, then no further member liability will apply for some or all covered services for the rest of the family. Not all services may be subject to the deductible and/or out-of-pocket maximum.
A dental HMO plan typically has a closed network of dentists, other dental providers, and dental facilities. With a dental HMO plan, a member receives services from the HMO’s providers for a predetermined level of coverage as described in your Evidence of Coverage. A member pays for services according to their plan’s benefits and doesn’t have to worry about submitting claims forms unless he or she receives dental services outside of the network.
An HSA is a tax-advantaged savings account that a member can open to pay for qualified dental expenses. Contributions to an HSA can be made by both a member and his or her employer, but the money belongs to the member. The money invested in an HSA is tax-deductible, and any earnings are tax-deferred. The member can withdraw funds tax-free and without penalty from the account if the funds are used to pay for qualified dental expenses. The HSA is portable and goes with the member if the member changes jobs.
Tax references are applicable per federal tax regulations. State tax regulations may vary. (See the Internal Revenue Service’s list of qualified medical and dental expenses.)
In network means a group of dentists, facilities, and other providers that have contracted with our dental plan to provide services to our members at negotiated rates. With all Kaiser Permanente dental plans, members typically pay less out of pocket when seeking covered services from an in-network provider.
Member liability is the financial obligation a member has when obtaining health care services. Copays, deductibles, and coinsurance are examples of member liabilities.
Out-of-network means a group of dentists, facilities, and other providers that have not contracted with a dental plan to provide services to our members at negotiated rates.
Members typically pay more out of pocket when seeking services from an out-of-network provider. Depending on a member’s plan benefits, the plan may or may not pay for a portion of the charges from out-of-network providers.
An out-of-pocket maximum is the limit to the total amount of deductibles, copays, and coinsurance an individual or family must pay in a calendar, contract, or plan year for covered dental care services.
At Kaiser Permanente, once the out-of-pocket maximum is reached, Kaiser Permanente pays for most or all of the covered services for the remainder of the calendar, contract, or plan year, depending on the plan. All covered services may not be subject to the out-of-pocket maximum.
In a Kaiser Permanente preferred provider organization (PPO) plan, members can choose from 2 coverage options each time they need dental care to get the health care that best meets their needs.
• In Option 1 or Tier 1 (contracted network), a member may receive care from a provider in a contracted network. The member is responsible for meeting a deductible and paying coinsurance for services.
• In Option 2 or Tier 2 (out of network), a member may receive care from any licensed provider or dental facility that is not part of the dental plan’s network of contracted providers. When a member chooses this option, he or she will generally have higher out-of-pocket expenses than if he or she had used Tier 1. The member is also responsible for satisfying a deductible and/or paying coinsurance charges.
A service area is a designated geographic area covered by a member’s dental plan.