When shopping for insurance, one of the top three types of insurance to consider is dental. There are several types of dental plans, some of which are pretty straight forward. All dental plans are designed to save you money but like all insurance, no two plans are alike. One of the common dental plan types is the Maximum Allowable Charge, or MAC plan. These plans can also sometimes be referred to as PPO fee plans. Within the realm of the DPPO plans, we can divide coverage in to MAC plans and UCR plans. Both plans are named for how they calculate payment to the dentist and your coverage.
How MAC Plans Differ
A Usual, Customary, and Reasonable, or a UCR plan calculates the reimbursement schedule based on where you receive treatment. Under a UCR, the amount the insurance company will pay the dentist is based on all claims that have been submitted for that particular service in a geographic area. The UCR plan will then pay out a certain percentage of the usual charge. This percentage can vary by plan, but it is usually 80 or 90%. Therefore, insurance will pay the percentage of what the usual charge for that geographic area. If the dentist charges higher than other dentists in that area, then the patient will be responsible for what is not paid by the insurance company when going to an out-of-network provider.
With a MAC plan, the reimbursement schedule from the insurance company to the dentist is capped at the maximum allowable charge (hence the name of the plan) which is set regardless of geography. The rates charged per procedure are negotiated between the insurer’s in-network dental providers and the insurance company. The insurance company uses these negotiated in-network fees to determine the reimbursement if a member sees an out-of-network provider for treatment. This means the insurance company will only pay a set dollar amount to the dentist, and you will be responsible for the remainder. One reason these plans have become more appealing in recent years is the typically lower premiums compared to UCR options.
How to Assess a MAC Plan
Possibly the biggest factor in choosing a MAC or UCR plan is twofold. How much dental work you expect to need in the near future, and whether your dentist is in-network.
- If you need a major procedure within the next year, be sure to note any waiting periods. If possible, ask the prospective dental providers for a sample schedule of payments and compare it to a quote from your dentist for a certain procedure.
- Like most insurance, using a dentist that is in your network will save you significantly more money than using one that is out-of-network. Before choosing a MAC plan, be sure your existing dentist is within your new network, or if there is one nearby who is accepting new patients.
If your group is looking to change to a new dental plan, or needs more information on how to educate yourself or your employees on benefits, contact one of our consultants to get help.