Understanding your insurance plan is very important and can have a huge impact on how you access your benefits. To help you out, we’ve provided a glossary for terms used at BEST Health Plans.
Active Status means the employee who is insured and is performing on a regular, full-time basis for the number of hours per week the employer has designated. In most instances, an employee must be in an Active Status to be eligible for coverage. 
A type of filling made up of several metallic materials. Amalgams are silver in color and are usually used on posterior (back) teeth.
The person designated by the member to receive the proceeds of a policy. This is mostly applicable to life insurance.
Calendar year is counted as beginning with January and ending with December.
The maximum amount BEST Health Plans will cover for that year. The maximum amount is the amount provided on the Schedule of Benefits within a plan’s Certificate of Insurance.
Cavities or tooth decay.
A formal document of the policy that details the benefits, exclusions and limitations of the plan. This document is the employee’s official copy of the policy and is also proof of insurance when there is a sticker on the front.
A demand made by the insured, the insured’s beneficiary, or on behalf of an insured, for the payment of the benefits as provided by the policy.
Federal legislation (The Consolidated Omnibus Budget Reconciliation Act) that gives workers and their dependents the right to continue group health benefits for an extended time. COBRA is offered under certain circumstances such as job loss, reduction in hours, death, divorce, and etc. Members who qualify for COBRA may be required to pay the entire premium amount to continue their coverage.
The percentage BEST Health Plans will cover for a category of treatment procedures. Depending on the plan and whether it is dental or medical, each category or treatment may have a different coinsurance. Any amount over the percentage is the financial responsibility of the member’s.
A white-color filling designed to match the natural color of teeth that is usually placed on the anterior (front) teeth.
A service or supply intended to alter a person’s appearance.
A medically necessary health care service or supply or dental treatment, which is not experimental or investigational, and which is prescribed or provided by a provider or physician for an injury or illness or preventive care.
The amount that must be met before claims are processed. In some cases, the deductible will apply after the maximum amount covered for that service is met. There are individual deductible amounts and family deductible amounts. How family deductible amounts are met varies by the type of insurance and plan selected. Please refer to the Schedule of Benefits section of your Certificate of Insurance to find out how your plan’s deductible works.
An employee’s spouse, child or domestic partner, if offered. An eligible dependent is a dependent who meets the requirements to receive benefits under the employee’s plan.
The expenses incurred by a covered person for a covered service.
The requirements that must be met before an employee or an employee’s dependents can enroll for coverage on an insurance plan.
An emergency is the sudden onset of a medical condition that causes symptoms of severe pain or bleeding, and which a prudent layperson with average knowledge of medicine can believe that immediate care is needed.
A statement that shows how BEST Health Plans processed a claim. An EOB will usually include the charges made by the doctor or dentist, any network discounts deducted from the charge, and any amounts the member will be responsible for. EOBs are not billing statements, and doctors/dentists will bill members directly for any amounts not covered by their plan.
A type of insurance plan that is designed to offer the same benefits, regardless of which provider a member goes to for services. Some indemnity plans provide access to a PPO network, where members can receive services at a discounted rate. The policy’s Schedule of Benefits will explain if this is an option.
A preferred provider inside the PPO service area.
A covered employee who is insured under an insurance policy, and sometimes where applicable, may refer to any of the employee’s covered dependents.
The diagnosis or treatment of an illness, injury or condition that is known to be appropriate according to generally accepted medical/dental practices and professionally recognized medical/dental standards.
A facility or health care professional that is not contracted with BEST Health Plan’s PPO network.
A non-preferred provider outside the PPO service area or who is within the PPO service area, but who is not contracted with the PPO network.
A health care, eye care or dental care professional that is contracted with a PPO network to provide services to members at a discounted rate.
An insurance plan BEST Health Plans provides to groups and/or individuals.
An employer, trustee of a fund established by an employer, association, labor organization, or other group permitted by the state to purchase group insurance.
The geographical area where Preferred Providers may be accessed at the Preferred Provider contracted rates.
A condition that existed before an Insured has enrolled on the insurance plan. In most cases, pre-existing conditions are not eligible for coverage. For specific information on what is considered a pre-existing condition, please refer to your plan’s Certificate of Insurance.
A type of insurance plan that gives members access to a network of providers who are contracted to provide care at a discounted rate, with the option to seek care outside of the network. In most cases, members will pay more when they receive care outside the PPO network.
The price for a group insurance policy. This amount is usually set on a monthly basis and is paid for by the employer.
The average and fair cost for treatment based on the dentist’s specialty, geographical location, and procedure. Applies to dental only.
There are two types of waiting periods, one that the employer controls and one that is part of a dental plan.
In the case of the employer, your organization may determine a length of time a newly hired employee must wait before becoming eligible to enroll for the company’s benefits. This waiting period is determined by the employer and once the employee is enrolled, does not have any impact on how benefits are covered by BEST Health Plans.
Some dental plans include a waiting period, which is the length of time an Insured must be enrolled on the plan before services listed under Major and/or Orthodontia are eligible for coverage. In this case, BEST Health Plans will not process claims for major or ortho services until after the waiting period is met. Some groups may have this waiting period waived.
Please note that your dental plan includes exclusions and limitations, these either explain how services are covered or provides a list of services excluded from coverage. Waiting periods do not have any affect on exclusions and limitations. If your plan’s waiting periods are waived, any limitations and exclusions will remain and cannot be waived.
An example is the missing tooth exclusion. On your dental plan, the cost of a prosthetic device to replace teeth missing before an Insured is covered by the policy is not covered. However, it is covered only when it also replaces a tooth that is extracted and after the Insured has remained continuously covered under this plan for at least three years, immediately prior to the date of prosthetic installation. This exclusion remains in tact even if your group is waived from waiting periods.
The yearly amount that must be met before claims are processed. In some cases, the deductible will apply after the co-pay and/or maximum amount covered for that service is met. There are individual deductible amounts and family deductible amounts. How family deductible amounts are met varies by the type of insurance and plan selected. Please refer to the Schedule of Benefits section of your Certificate of Insurance to find out how your plan’s deductible works.
