Dental insurance terms, explained in plain language
Plan booklets are full of jargon. This glossary explains the words you're most likely to see on an estimate or claim.
Your deductible is what you pay before the plan starts paying. Co-insurance is the percentage the plan covers. The annual maximum is the most it will pay in a benefit year. A predetermination asks the insurer what it will pay before treatment. Coordination of benefits applies when two plans share the cost.
Costs and coverage
- Deductible: the amount you pay each benefit year before your plan begins to pay; some plans have none
- Co-insurance: the percentage the plan pays for a service, such as a share for basic care and a lower share for major care; you pay the rest
- Co-payment: your share of the cost; with the Canadian Dental Care Plan, the co-payment depends on your family income
- Annual maximum: the most the plan pays per person in a benefit year; it usually resets at the start of each benefit year
- Lifetime maximum: a limit over your whole time on the plan, often used for orthodontics
- Benefit year: the 12-month period your plan uses, which may be the calendar year or another date
Categories of care
Most plans group services into categories with different coverage levels. The exact groupings vary by plan.
- Preventive or basic: exams, cleanings, X-rays, fluoride and sealants
- Basic restorative: fillings, extractions and sometimes root canals and gum treatment
- Major: crowns, bridges, dentures and implants
- Orthodontic: braces and clear aligners such as Invisalign, if included
Rules and limits
Plans also often have rules for replacing existing work, such as a crown or denture, only after a set number of years. If you're unsure whether a limit applies to you, ask your insurer before treatment.
- Frequency limit: how often a service is covered, such as one exam every 9 or 12 months or one set of bitewing X-rays per year
- Recall: a routine checkup and cleaning; plans often limit how often these are covered
- Waiting period: time after joining a plan before some services are covered
- Alternate benefit: when the plan pays for a lower-cost option, for example a metal filling instead of a white one, and you pay the difference
- Fee guide year: the version of the Ontario Dental Association fee guide your plan uses to calculate payment
Claims and billing
Keep your plan booklet or member portal handy when you book a larger treatment. With your policy and certificate numbers, the office can check coverage and send a predetermination for you.
- Predetermination (pre-authorization): the dentist sends the treatment plan to your insurer, which replies with what it will cover
- Direct billing (assignment of benefits): the office sends the claim and the insurer pays the office directly; you pay only your share
- Coordination of benefits: when you're covered by two plans, such as your own and a spouse's, the primary plan pays first and the secondary may cover some of the rest
- Explanation of benefits: the statement from your insurer showing what was paid and why
Frequently asked questions
Which plan is primary if I have two?
Your own plan is usually primary for you. For children covered by both parents, many insurers use the birthday rule: the plan of the parent whose birthday comes first in the year pays first. Check with your insurers to confirm.
Do you bill my insurance directly?
Yes. Our office bills insurance companies directly and accepts the Canadian Dental Care Plan. We can also send predeterminations for larger treatment.
Why did my plan pay less than I expected?
Common reasons include a deductible, an older fee guide year, a frequency limit, an alternate benefit or reaching your annual maximum. Your explanation of benefits will show which applied.
Does unused coverage roll over?
Most plans don't carry unused annual maximums into the next benefit year. Check your plan booklet or ask your insurer for your plan's rules.
Related services
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Trusted health information
General information only; not a substitute for an exam. Reviewed by Dr. Sayeh Maralani, DDS, general dentist. Last updated 2026-11-05.
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