Insurance Glossary

ERISA (Employment Retirement Income Security Act) is a federal law that establishes standards and reporting requirements for health plans to provide protections for covered members. There are many elements of ERISA that relate to self-funded (ASO) dental plans as well as dental plans insured by a carrier. Some types of organizations are exempt from ERISA provisions.

The effective date marks the beginning of a plan year. The effective date may also be referred to as a plan anniversary.

Once an individual has enrolled in a dental plan, usually during an open enrollment period, that individual and any covered dependents will be eligible for benefits at the start of the plan year. Refer to your dental plan summary for specific details as some dental plans may have waiting periods past the eligibility date for some services. The eligibility date is often referred to as the dental plan's effective date.

See "Covered person" or "Member"

Certain dental services are ineligible for dental plan reimbursement. These are called dental plan exclusions, and they are outlined in the dental plan summary. Exclusions may include such things as cosmetic services, treatment that is considered to be a dental plan expense, or services that are temporary or experimental. 

An expiration date is the last day a dental plan member is eligible for benefit reimbursement for services rendered. Typical examples of when an expiration date occurs include when a current dental plan member elects not to enroll in dental benefits for the upcoming plan year, if a member changes jobs, or when a dependent can no longer be covered due to age limitations.

When a dental plan administrator issues reimbursement, members receive an explanation of benefits (EOB) outlining the services provided, the dental plan reimbursement, and the member's out-of-pocket cost obligation. An EOB is not a bill. The dentist will generally bill members directly for their cost obligation.