Let’s been honest, a lot of dental plans and coverage can be confusing. Especially when you are not sure of how much you may pay for a certain service or what your plan covers. In the dental insurance world, there are two primary styles of coverage and how they determine how much you will pay.
To make sense of how this works, you’ll need to know whether you have a MAC plan or a UCR plan and understand the difference. MAC stands for Maximum Allowable Charge and UCR which stands for Usual, Customary, and Reasonable. Basically, these terms refer to the way that coverage is determined when you visit an out-of-network dentist.
Under a MAC plan, the reimbursement for services provided by an out-of-network dentist is capped at the Maximum Allowable Charge (MAC). For example, if you visit an out-of-network dentist who charges $150 for a cleaning (covered at 100%), but the MAC is set at $100, insurance will cover $100 and you will be responsible for the remaining $50.
Under a UCR plan, the limit on reimbursement is set based on the Usual, Customary, and Reasonable (UCR) value for your geographic area. A UCR value is calculated for each dental procedure by tracking all the claims that have been submitted for a particular procedure within a particular geographic area. The UCR value is then set at a level where a certain percentage (usually 80 or 90%) of fees charged for that procedure in that area are less than the UCR value. Complex right?
How about I try to simplify with an illustrative example: two fictional people who have dental insurance plans with Acme Insurance, Mack and Ursula. Say Mack and Ursula both need a filling and they decide to see the same dentist, Dr. Tooth, for the procedure. Dr. Tooth, being one of the best dentists in the area, charges $200 for a filling. Unfortunately, Dr. Tooth is not a part of the Acme network, so both Mack and Ursula are subject to out-of-network coverage. Let’s see what they’ll each owe.
First up is Mack’s appointment. Mack is enrolled in an Acme Insurance MAC plan, and under Mack’s MAC plan, fillings are covered at 80%. The PPO Fee for fillings on his plan is set at $150, so Acme Insurance will reimburse Mack $120 (80% * $150) and Mack will be responsible for paying Dr. Tooth the remaining $80.
Later that day, Ursula has her appointment. Ursula is also enrolled in an Acme Insurance plan, but hers is a UCR plan. The UCR percentile on her plan is set at 90%, which comes out to a UCR Value of $180 in her area. Dr. Tooth charges $200 for a filling, so Acme Insurance will cover $144 (80% * $180) and Ursula will cover the remaining $56.
|Dr. Tooth’s Charge||$200||$200|
|Acme Insurance Max||$150 (PPO Fee)||$180 (90th Percentile UCR)|
|Service Level Charge||$120 (80% * $150)||$144 (80% * $180)|
Now I know that was a lot to take in hopefully this should clear up some of the more confusing points. The important thing to remember here is that these are examples and does not necessarily mean that one style of dental plan is better than the other. It is important to look at these things with your broker or agent to understand what might be best in your area.
In this example, Ursula owed less money to Dr. Tooth than Mack owed with his MAC plan. Does this mean that either option is better? Not necessarily. UCR plans are sometimes preferred in areas where the number of in-network dentists is not as strong or if a group has a high number of members who see out-of-network dentists. A UCR plan guarantees that 80-90% of dentists in a geographic area charge less than the UCR Value for a certain procedure, so there’s a good chance that seeing an out-of-network dentist won’t be more expensive than seeing an in-network dentist. MAC plans are typically more affordable, but their fee schedule means it’s more likely that seeing an out-of-network dentist could be more expensive than seeing an in-network dentist. So, they’re usually a better choice for groups in areas with larger numbers of in-network dentists, and groups whose members are already patients of in-network dentists.
If this all seems complicated, a licensed insurance agent can help you understand the options that are best for you and your family. Our Phoenix Captive Solutions staff are always more than willing to help.
This article was written by Phoenix Captive Solutions C.F.O. Blake Coats, any views or opinions do not necessarily reflect the opinions of either Phoenix Captive Solutions LLC, or any associated entities.
Feel free to write to Blake at firstname.lastname@example.org