Glossary

Abutment:

A tooth used to support and anchor a fixed or removable denture prosthesis.

Amalgam Filling:

A mixture of mercury, silver, and other materials, used to restore teeth.

Amount eligible:

The portion of the amount submitted that is eligible for whole or partial reimbursement by your plan.

Amount submitted:

The amount you were charged for a product or service.

Anaesthesia:

Drugs used prior to dental treatment to eliminate discomfort. There are two main categories of anaesthesia – Local and General.

• Local anaesthesia – The most common form of anaesthesia, it causes loss of sensation or feeling to a localized or specific area. It is administered by injecting an anesthetic agent near the area in the mouth to be treated.
• General anaesthesia – Causes the patient to become unconscious during the treatment. It is administered either by the inhalation of a gas or by injection into a vein (intravenously).
• Conscious sedation is another type of anaesthesia. This is a management technique that uses inhaled nitrous oxide gas to assist the patient with fear and anxiety so that they can cooperate with the dental treatment. The patient does not lose consciousness during the procedure. Manulife does not pay benefits for conscious sedation.

Benefit Year Maximum:

A benefit year maximum can apply to certain types of coverage within your plan. It may limit the number of visits to a particular practitioner, the number of times that a specific procedure can receive payment as a claim. It may limit a practitioner or procedure to a specific dollar maximum. The limitations are assessed and accumulate within the plan's benefit year. When the next plan year begins, the maximums reset to their full value.

Calendar Year Maximum:

A calendar year maximum can apply to certain types of coverage within your plan. It may limit the number of visits to a particular practitioner, the number of times that a specific procedure can receive payment. It may also limit a practitioner or procedure to a specific dollar maximum. The limitations are assessed and accumulate within a calendar year. When the next calendar year begins, the maximums reset to their full value.

Coinsurance:

The percentage of the amount eligible that your plan covers, sometimes referred to as percent paid. For example, if your plan covers 80% of the amount eligible, then you will not be reimbursed for the other 20%.

Composite Filling:

A white plastic material used to restore teeth.

Coordination of Benefits:

If you have health or dental coverage under another plan, you can get up to 100% of your eligible expenses covered. Industry-wide procedures, determined by Canadian Life and Health Insurance Association (CLHIA) guidelines, establish which plan considers a claim first. Through coordination of benefits, you can submit the unpaid part of a claim to the second plan for payment. For example, if this plan pays 80% of an expense, the other plan may pay the remaining 20%.

Here's how to take advantage of coordination of benefits

For you
Send your claims to your plan first. Then submit the claim statement -- along with copies of receipts -- for any unpaid portion to your spouse's plan.

For your spousestrong>
Send your spouse's claims to his/her plan first, then submit the claim statement -- along with copies of receipts - for any unpaid portion to this plan.

For your children

1. If you are the parent whose birthday (month and day) falls EARLIER in the year, submit your children's claims to your plan first. Then, submit the claim statement for any unpaid portion to the other parents plan.
2. If you are the parent whose birthday (month and day) is LATER in the year , submit your children's claims to the other parents plan first. Then submit the claim statement for any unpaid portion to your plan.

Copayment:

The copayment is the contribution you are required to make towards certain expenses covered under the group plan.

Crowns:

Also called a cap, a crown is needed on a tooth when the tooth is weakened by decay, fracture or a very large restoration. A crown is usually made of porcelain and or metal. You will need to submit x-rays with your claim before it can be considered for payment.

Deadline To Incur Expenses:

Expenses in the plan year will be eligible for submission up to this date.

Deadline To Submit Claims:

Expenses incurred in the plan year can be submitted up to this date.

Deadline to incur expenses against unused funds:

You must receive and pay for an eligible service prior to this date in order to submit a claim against the unused funds during the carry-forward year. The carry-forward year is the period during which you are entitled to use any unused funds from the previous Plan Year.

Deadline to submit claims against unused funds:

Receipts for any eligible service or expense you paid for prior to the Deadline to Incur Expenses Against Unused Funds must be submitted by this date.

Deductible:

The eligible expenses we deduct from your claim before your plan pays a benefit.

Dental Coverage Deductible:

Your deductible may be shared between several categories of services.

Example:

A plan may have a $25 deductible for Preventative Services, and a $25 deductible for Basic Restorative Services. This means that satisfying the deductible for Preventative Services also satisfies the deductible for Basic Restorative Services.

See your benefit booklet or Plan Administrator for details of your deductibles.

Dental Coverage Maximum:

Some dental services may be combined to calculate your coverage maximum.

Example:

A plan may have a $500 maximum for Preventative Services, and a $500 maximum for Basic Restorative Services. This means that meeting the maximum for Preventative Services also reaches the maximum for Basic Restorative Services.

See your benefit booklet or Plan Administrator for details.

Dental Fee Guides:

The dental association of each province publishes a dental fee guide. This guide summarizes recommended charges for each dental procedure. Guides are updated annually to account for inflation and other factors.

Plan sponsors can choose which dental fee guide to use to determine the maximum amount payable for each dental procedure in their plan (e.g. the dental fee guide for the current year, for a specific year, or for a specific province.)

Denture

A denture is a synthetic replacement for some or all of your teeth in either your upper or your lower jaw.

Dependent Child

A dependent child is a plan member's natural child, adopted child or stepchild (a stepchild must be living with the plan member) who is:

• unmarried;
• not employed on a full-time basis;
• ineligible for insurance as a plan member under this or any other group plan; and below the age specified in the dependent definition section of the plan member's plan.
• An over-age dependent child must meet the requirements above and be a full-time student at an accredited school, college or university;

and/or

• disabled; and
• unable to work full-time.

Diagnostic Cast

Also called a study model, a diagnostic cast is a replica of the form of the teeth and tissues made from an impression.

Diagnostic Services

Diagnostic services assist the dentist in evaluating the existing condition of a patient's mouth. These services are used to determine what dental treatment, if any, is needed. Examples of diagnostic services include:

• initial
• recall, and
• emergency.

Direct Deposit

The electronic transfer of a payment from a company or organization into the chequing or savings account of employees or customers.

Drugs

Active Ingredient / Chemical Name

This is the name of the main ingredient contained in the drug product.

Brand Name

This is the Brand or Trade name under which the drug product is marketed.

Dispensing Fee Cap

The plan sponsor can place a fixed dollar limit on dispensing fees (the fee charged by a pharmacy for filling a prescription).

Drug Formulary

A drug formulary is a defined list of medically effective and cost-effective drugs. Most commonly used drugs are included in the formularies used by Manulife. Drugs that are not covered have a suitable alternative within the defined list of drugs and are available at a lesser cost with similar, equally-effective medical results. Your local pharmacist can provide you with a current list of eligible drugs or acceptable substitutes.

Drug Identification Number (DIN)

The Drug Identification Number (DIN) is assigned by Health Canada to each drug approved for sale in Canada in accordance with the Food and Drug Regulations. A DIN is assigned to all approved prescription and over the counter drugs.

Generic drugs

Generic drugs are a chemically equivalent alternative to brand name drugs. They contain the same high quality active ingredients as brand-name drugs. They are federally tested using the same strict criteria for safety and effectiveness and must meet the same scientific norms and standards.

Generic drugs' inactive ingredients, such as coatings, may differ (although the fillers used in drugs come from a limited range of available products) and they may appear different – in colour or shape – but they work the same. They are less expensive than brand-name drugs.

Over-the-Counter Drugs

Over-the-counter drugs are drugs that do not require a prescription in order to be purchased.

Prescription Drug Plan

A Prescription Drug Plan is one including drugs that, by Federal or Provincial legislation, require a prescription for dispensing and sale, and which have a valid Drug Identification Number (DIN).

Prescription drugs are only available from a pharmacy when prescribed by a physician to treat or prevent a medical condition, e.g., insulin.

Prescribed Drug Plan

A Prescribed Drug Plan is one including drugs that, by Federal or Provincial legislation, require a prescription for dispensing and sale, and which have a valid Drug Identification Number (DIN). Drugs recommended by a physician (using a written prescription), including over-the-counter drugs are also covered.

Therapy Class

A therapeutic class is described as a group of drugs that are similar in chemical structure, pharmacological effect and/or clinical use. The drug(s) have essentially the same effect in the treatment of disease or condition as one or more other drug(s) in that class.

Endodontics:

Endodontics is a branch of dentistry that involves treating the inside of a tooth. Many teeth can be saved by the removing the pulp inside the tooth rather than the whole tooth itself.

Fluoride:

Fluoride is applied to teeth to reduce or prevent decay.

Inlays / Onlays and Pins:

An inlay or onlay is a gold, porcelain, or composite custom-made filling cemented to the tooth. A pin helps to stabilize the tooth and support the inlay or onlay in the restoration.

Late Applicant or Application

An application is considered late if you:

• Apply for insurance on any person after having been eligible for more than 31 days; or
• Re-apply for insurance for yourself or a dependent whose insurance had earlier been cancelled.

If you apply for benefits that were previously waived because you were covered under similar benefits with your spouse's plan, your application is considered late if you:

• Apply for insurance more than 31 days after the date benefits terminated under your spouse's plan; or
• Apply for insurance and benefits under your spouse's plan have not terminated.

Late Filed Limits:

Most plans include a deadline for submitting claims. After the deadline has passed, claims will be declined as late filed.

Example:

Your plan may state that all claims must be submitted within 12 months of the date the expense was incurred. In this case, if you submit a claim where the date of service was over 12 months ago, the claim will be declined.

Maximums

A maximum for a benefit can refer to the

• age limit,
• dollar limit and/or
• time limit

to which you and your covered family members are eligible to receive benefit coverage.

Example of an age maximum: A plan member and the covered family members are eligible to receive health benefit coverage under the plan until the member reaches 65 years of age.

Example of a dollar and time maximum: A plan covers a plan member's prescription drugs up to $10,000 per calendar year.

Medical Services, Supplies and Equipment:

The following medical services may be covered:

• private duty nursing,
• diagnostic procedures,
• medically necessary ambulance services,
• dental treatment for accidental injuries to teeth.

The following medical supplies and equipment may be covered:

• medically necessary equipment rentals such as wheelchairs and hospital beds,
• non-dental prostheses, supports and hearing aids,
• ileostomy, colostomy and incontinence supplies,
• medicated dressings, burn garments, oxygen.

See your benefit booklet or Plan Administrator for more information.

Occlusal Equilibriation:

Occlusal equilibriation or occlusal adjustment is a procedure that involves reshaping the occlusal (biting) surfaces of teeth to create even contact between upper and lower teeth. The procedure is performed quadrant by quadrant (one section of the mouth at a time) and may require several appointments to fully equalibriate a patient's whole mouth.

Open Space Limitation:

The Open Space limitation may apply to certain dental procedures that use appliances to replace extracted teeth. When a dentist recommends placing a prosthodontic appliance – such as a bridge or a denture – as part of the patient's treatment plan, Manulife needs to know the extraction date for each tooth that the appliance will be replacing. If your plan includes this limitation, and any of the teeth involved were extracted before the patient became insured under the plan, Manulife will not pay for the treatment. Check your benefit booklet, or with your plan administrator to see if your plan includes the Open Space limitation.

Oral Hygiene Instruction:

Oral hygiene instruction provides information about how to brush, floss, and care for teeth.

Oral Surgery:

This branch of dentistry deals with the surgical treatment of diseases or defects of the mouth. Manulife has two categories of oral surgery:

• Basic – Examples of basic services include tooth extractions and removal of cysts or tumors.
• Major – Examples of major services include transplanting erupted teeth and alveoplasty (reshaping and trimming the bone in an area where there are no teeth present).

Check your benefit booklet, or with your plan administrator to find out if your plan's coverage includes both categories of oral surgery.

Orthodontics:

This area of dentistry is concerned with growth of the jaw, development of the bite, and correction of dental and facial abnormalities. Orthodontic treatment involves the placement of braces, retainers, and orthodontic appliances to eliminate dentofacial abnormalities in patients.

Percent paid:

The percentage of the amount eligible that your plan covers, sometimes referred to as coinsurance. For example, if your plan covers 80% of the amount eligible, then you will not be reimbursed for the other 20%.

Periodontal Disease/Periodontitis:

Periodontal disease is an advanced gum disease resulting in the deterioration of the supporting structures of the teeth.

Periodontal Appliance:

Also known as a habit-breaking appliance, a periodontal appliance is designed for a patient who grinds or clenches his or her teeth. Using a periodontal appliance can relieve jaw pain and prevent further tooth damage.

Perio-scaling/Periodontal Scaling:

Perio-scaling removes deposits of plaque, tartar, and food debris that have accumulated on teeth or beneath the gum tissue.

Pit and Fissure Sealants:

Pit and fissure sealants are plastic coatings applied to grooves of molars to prevent decay.

Plan Allocation:

The annual funds allocated to your benefit for the plan year. The value may change if the plan allocates funds with a frequency other then annual.

Plan Year:

Is the year your benefit is available and aligns with the plan year of your health and/or dental benefits.

Polishing:

Polishing a tooth's surface make it smooth and therefore more difficult for plaque and debris to accumulate and cause decay or gum disease.

Pre-determination of Benefits:

When a proposed course of dental treatment is expected to cost more than $300, a treatment plan should be filed in advance with Manulife. The dentist outlines the treatment plan, and Manulife issues an Explanation of Benefits (EOB) to the plan member describing the exact amount covered by the benefit plan for the treatment.

This provision is a service feature allowing the plan member to make an informed decision before proceeding with an expensive dental procedure. If a plan member does not have his or her dentist submit the treatment plan, this will not compromise or invalidate the eligibility of the claim. However, only eligible expenses will be reimbursed as defined in the plan.

Preventative Services:

Preventative services are dental procedures and actions that keep your teeth healthy and prevent disease and decay. Regular dental examinations and oral hygine instruction are examples of preventative services.

Professional Services

The following professional services may be covered depending on your plan:

• chiropractors
• osteopaths
• podiatrists
• massage therapists
• naturopaths
• speech therapists
• physiotherapists
• psychologists.

Professional services can be subject to calendar year maximums for each practitioner, as well as reasonable and customary dollar maximums per visit.

For a professional services claim to be eligible for coverage, the following requirements must be met:

• the practitioner must be licensed in his or her field; and
• in most provinces, the overall maximum benefit (per visit and yearly maximum) under the provincial plan has been paid.

Note: Referral to a practitioner by a physician may be required. See your benefit booklet for the complete list of professional services covered under your plan.

Prophylaxis:

Prophylaxis is cleaning your teeth.

Prosthetic:

A dental prosthetic is an appliance that replaces missing teeth. Manulife has two categories of prosthetics: Basic and Major.

Prosthodontics:

This branch of dentistry is concerned with replacing missing teeth and surrounding tissue using an artificial appliance, The appliance could either be fixed – like a bridge – or removable like a denture. Manulife has two categories of prosthodontic services:

• Basic – Relining, Rebasing, or Repairing of a Denture
• Major – Bridgework, Denture (partials and complete)

Check your benefit booklet, or with your plan administrator to find out if your plan's coverage includes both categories of prosthodontics.

Reasonable and Customary (R&C):

A fee is reasonable and customary if its dollar value falls within the usual range of charges for the same or comparable services (or supplies) made by similar practitioners in an area.

Example:

The fee a dentist in Ontario charges for a check-up is reasonable and customary if it is within the range of fees that Manulife deems reasonable, based on information from the Ontario Dental Association.

Restorative:

Restorative services are provided to repair and restore natural teeth to their normal function. Manulife has two categories of restorative services:

• Basic – An example of a basic restorative service is a filling.
• Major – Examples of major restorative services are inlays, onlays and crowns.

Check your benefit booklet, or with your plan administrator to find out if your plan's coverage includes both restorative service categories.

Root Canal Treatment:

A root canal treatment is a method of saving a tooth by cleaning out a damaged nerve within a root and filling in the resulting chamber.

Space Maintainers:

A space maintainer is a dental device used to maintain a space in your mouth. A space maintainer may be used when a baby tooth is lost. The device holds a space in your mouth until a permanent tooth comes in to fill that space.

Spouse:

A spouse is a plan member's legal spouse or a person living with the plan member in a role like that of a marriage partner.

Temporary crown:

A temporary crown is made of metal, acrylic, or plastic, and is used over a prepared tooth until a permanent crown can be placed.

Unused Funds Available Until:

Unused funds at the end of the plan year are carried forward for one year. To use these funds, you must incur the expense during the plan year the funds were carried forward into. Claims must be submitted by the date displayed.

Veneer:

Veneers are thin sheets of porcelain which are bonded onto the front side of teeth to make a cosmetic improvement in their appearance. Veneers can repair teeth that are stained, worn, chipped or slightly misaligned.

X-rays, Radiographs or Diagnostic Imaging:

Bitewing X-ray

Bitewing X-rays show the top halves of the upper and lower teeth on the same film. This allows the dentist to determine the presence of decay or cavities in between teeth.

Cephalometric X-ray

A cephalometric x-ray shows a side profile of the patient's entire head. The picture includes the upper and lower jaws, and illustrates how they support the teeth. This kind of x-ray is commonly used to determine a course of orthodontic treatment since it includes enhanced images of the soft tissues of the face.

Extraoral Films

With extraoral films, the x-ray film is housed inside a casette and placed outside the mouth with the x-ray machine aligned outside the mouth on the side opposite the cassette. The most common extraoral radiographs are panoramic and cephalometric. These views accomodate the jaw in the image whereas intraoral films are generally smaller and used primarily for visualizing teeth only.

Panorex Films

A panorex film or panoramic x-ray makes a complete half circle from ear to ear to produce a two dimensional representation of all of a patient's teeth and give an overall picture of the patient's teeth and jaw bones.

Periapical Films

Periapical films are x-rays used to provide images of the entire tooth from crown to root tip. They display the root, cysts, or abscesses that are involved with toothaches. They can also be used to check bone level around teeth and to evaluate bone loss that is caused by periodontal disease. Periapical films can also be used to assess existing dental work. These x-rays give fine details that are extremely important in diagnosis.