Fully Insured Indemnity Plan

Characteristics

Defined benefits with a fixed monthly premium

Benefits are paid off of a UCR Schedule. UCR (usual and customary fees) is a data base compiled by an insurance company to reflect regional charges for dental procedures. UCR vary from company to company depending on the sampling of the data, the date of the sampling, and criteria protocols. UCR can vary significantly.

Benefits are paid by percentages of UCR. Preventive services are usually 100%, basic services 80%, and major services 50%.

Example: if dental charges for a cleaning are $75.00, although paid at 100%, but the UCR is only $50.00, the patient is left with left with a $25.00 balance.

It is the UCR schedule together with deductibles and maximums that determines out of pocket expense.

-Benefits are limited to annual maximums, usually calendar year to calendar year, and usually $1000.00-$2000.00 maximums

-Normal deductibles range from $50.00-$150.00

-Dentistry for esthetic reasons is usually not payable

-Orthodontic coverage is usually limited to $500-$1000.00

-Implants are usually not covered

-Treatment for TMJ ( temporal-mandibular-joint dysfunction) are usually not payable

- Specialized diagnostic x-rays are usually not payable

-Vague wording such as " payable under special circumstances with documentation" usually is not a payable benefit.

*** Some plans use their own " fee schedule" rather than a "UCR" fee schedule: this typically results in a lower benefit.

*** Some plans are "customized" at the request of the employer making it difficult to compare.

To view an example of an " high-end plan" click here

To view an example of an "average plan" click here

To view an example of an " low-end plan" click here

Advantages

-Employees may choose their own dentist, or dental specialist, and may change at any time.

-Fixed monthly premiums are usually guaranteed for 6-12 months

Disadvantage

-The most expensive type of dental plan

-Benefits can be difficult to understand.

-May require waiting periods.

-Benefits are based on UCR fee schedule, which vary significantly.

Always ask to see the UCR schedule.

-Few carriers provide employers with claims experience data so cost effectiveness is hard to determine.

 

Purchase Considerations

-Carefully compare plans and UCR schedules

-How often is the UCR schedule updated?

-Check the UCR percentages. The higher the better

-Ask the carrier to provide claims expense report.

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©1998, Jeffrey Kohlhardt DDS, 1204 Cottonwood Street, Suite 4
Woodland, California 95695, (530) 662-7128 dr-k@dentalresource.com