In part 1 we described how a dental plan works, what type of services are covered and what key terms to look for so you can start narrowing down your plan options. In this issue will go into detail of how two insurances work together and discuss what usual and customary charges really mean. Even armed with all the information we have provided, choosing the right plan can still be quite the task and what worked well for you one year may not in the next. Don’t forget that you have help and we are simply a phone call or email away! While we can’t pick the plan for you, we will gladly help guide you and answer any questions so that you can fully maximize the benefits you pay for each year.
Usual, Customary and Reasonable Charges (UCR)
UCR charges are the maximum allowable amounts that will be covered by the plan. UCR rates are not required to meet any sort of industry standard, in fact it is the opposite: each company is able to set whatever amount they want for UCR charge and they may not match the current actual fees charged by dentists in any given area. Adding to the ambiguity of this line item is that the company is not required to disclose the formula or data used to compute the number. Low UCR rates mean low employer cost, low employer cost equals more employer participation and greater revenue for the insurance company.
Primary and Secondary Plans
If Patient A is the subscriber to a dental plan it would be their primary plan. If Patent A has a spouse who also has a dental plan, the spouses insurance would be Patient A’s secondary plan.
Birthday Rule: primary and secondary plans are determined differently for children and are usually designated using what is called the birthday rule: assigning the primary plan by which parent’s birth month comes first in the calendar year. A divorce agreement or other court ruling may supersede the birthday rule when determining which plan is primary and secondary.
Coordination of Benefits (COB)
If you have two dental benefit plans they will coordinate benefits one of two ways.
1) Standard Coordination: The secondary insurance will coincide with the primary on all claims.
Example: Mary’s Primary plays a filling at 80%, her secondary will pay the remaining 20%.
2) Non-Duplication (Non-Dup): The Secondary Insurance will not pay anything towards services the primary paid on unless the primary is completely maxed.
Example: Mary’s primary plan has $15 dollars remaining for the benefit year and pays that amount towards her filling. Her secondary insurance will not pay towards the filling, leaving the remaining as her responsibility. During the same benefit year Mary needs a second filling. Her primary plan is now maxed and will not pay towards this filling, but her secondary plan will now begin to pay and she will have her full benefit year maximum available.
Next up part three: What is the real cost for me and do I have other options?