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 insurance plans as well as dental insurance plans insured by a carrier. Some types of organizations are exempt from ERISA provisions.
Effective date
The effective date marks the beginning of a plan year. The effective date may also be referred to as a plan anniversary.
Eligibility date
Once an individual has enrolled in a dental insurance 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 insurance plan summary for specific details as some dental insurance plans may have waiting periods past the eligibility date for some services. The eligibility date is often referred to as the dental insurance plan's effective date.
Enrollee
See "Covered person" or "Member"
Exclusions
Certain dental services are ineligible for dental insurance plan reimbursement. These are called dental insurance plan exclusions, and they are outlined in the dental insurance plan summary. Exclusions may include such things as cosmetic services, treatment that is considered to be a dental insurance plan expense, or services that are temporary or experimental.
An expiration date is the last day a dental insurance plan member is eligible for benefit reimbursement for services rendered. Typical examples of when an expiration date occurs include when a current dental insurance 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.
Explanation Of Benefits (EOB)
When a dental insurance plan administrator issues reimbursement, members receive an explanation of benefits (EOB) outlining the services provided, the dental insurance 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.
