In the age of wireless portability, finding affordable medical and dental insurance has become more challenging. A quick online search will result in hundreds, if not thousands of companies and websites, competing for your click. So how can you really tell if your being offered the best coverage?
Any website claiming to offer comprehensive medical and dental coverage should provide online tools to help you not only assess the coverage you need, but be able to compare your selection(s) to other plans. If you are able to do comparisons, keep in mind the following terminology that may be used:
Most affordable medical and dental insurance plans may require you to submit a proposal of the treatment being requested and its associated costs. The insurance carrier decides both the maximum limits and the amount that the patient is responsible for. The dollar amount they pay can be reduced or limited by the deductible or maximum dollar benefit of the plan. Indemnity type plans usually use this predetermination benefits method. This method is considered an open panel insurance plan which allows patients to seek services from any medical or dental provider of their choice.
Many medical and dental insurance plans have limits on the amount of treatment you can receive annually. The precise methodology by which the insurance company determines the amount of payment they will make will vary from plan to plan, but it is usually based on one of the following two schemes:
Usual, Customary, and Reasonable (UCR) plans
These types of plans base their payment calculation on the insurance company's proprietary "usual, reasonable, customary" fee (a "UCR" fee) or the dentist's fee, whichever is less. For example, an individual has an affordable medical and dental insurance policy which states that the insurance company will pay for 80% of the cost of a dental filling. The dentist has determined that you need a dental filling, performs the procedure and charges you $100 for the service. When the dental claim is submitted to the insurance company, a comparison is made between the dentist's fee and their "UCR" fee for that particular procedure. If the company's UCR associates a fee of $120 for the procedure, they will pay 80% or $80 of the $100 that the dentist has charged you. Your out of pocket expense in this case will be $20 which is the difference between what the actual charge ($100) and what the insurance has paid to the dentist ($80).
Using the same example above, if the company's UCR is $90 for the procedure, they will pay 80% or $72 of the $90, not the $100 that the dentist has actually charged you. Your out of pocket expense in this case will increase to $28 which is the difference between the actual dentist's charge ($100) and what the insurance company will pay to the dentist ($72).
While overall it seems like a win-win situation for the insurance company, some may see the UCR fee as being more accurately representative of the fees charged by the majority of dentists in a given area. The unspoken implication here is that, if your dentist charges more than the dental insurance company's UCR fee, the dentist is actually charging too much. You can decide to either seek the services of another provider in the same geographical area or continue to pay a higher out of pocket cost for your treatment.
The reality of the matter is that there is wide fluctuation and no regulation on how most insurance companies calculate their UCR fees. It is difficult to determine whether or not an insurance company's calculations accurately reflect the fees charged by dentists in a specific area. While it is understandable why insurance companies need to incorporate such methods to contain their expenses, it is also quite obvious how an unrealistically low UCR fee schedule would favorably affect the insurance companies profits.
Table of Allowance plans
Using Table of Allowances, insurance companies utilize a list that outlines the dental procedures covered by the plan. Each procedure on the list has an associated set dollar amount that the plan will pay when performed. Not surprisingly, in almost every case, the fee indicated on the insurance company's Table of Allowance is less than what the health care provider charges. In practically every situation, the patient will always pay out of pocket to make up the difference.
If you are covered by more than one affordable medical and dental insurance plan (two dental and health insurance plans or two dental insurance plans or a dental and a health insurance plan), inform all providers accordingly. This helps to ensure that you get the full benefit from both plans and can be covered for any necessary treatments that may not be covered by one of the plans. Also, if you have a combined affordable medical and dental insurance plan, the medical portion may cover the costs of some dental treatment excluded by the dental insurance carrier.