The terminology and concept of “Deductible” must be understood first.
- The deductible is the amount of expense which the subscriber (aka: insured; aka: policy holder) must pay before benefits are covered by the insurance carrier.
- The deductible amount is covered 100% by the subscriber.
- The deductible is usually each benefit year dependent on the insurance plan’s anniversary year. While most dental insurance plans have a calendar year benefit period (January 1 through December 31), some insurance plans have a fiscal benefit year (i.e., April 1 through March 30).
- The deductible is applied to the patient’s first applicable procedure, according to the insurance plan setup.
- The deductible is always calculated first, before the estimated insurance amount is calculated.
- The deductible may be waived (aka: not calculated) for various dental categories.
Example #1: Deductible Waived Procedure
- Insurance plan setup:
- $50 individual deductible
- $2000 annual benefit
- Deductible waived on Diagnostic procedures
- Diagnostic procedures covered 100%
- D0120 – Periodic Oral Evaluation = Diagnostic procedure
- Fee = $85
- Estimated insurance = $85
- Estimated patient = $0
Example #2: Deductible Not Waived Procedure
- Insurance plan setup:
- $50 individual deductible
- $2000 annual benefit
- Deductible not waived on Restorative procedures
- Restorative procedures covered 80%
- D2391 – Resin Composite One Surface Posterior = Restorative procedure
- Fee = $200
- Estimated insurance = $120
- Estimated patient = $80
- Calculation:
- $200 fee - $50 deductible = $150
- $150 x 80% = $120 estimated insurance
- $200 fee - $120 estimated insurance = $80 estimated patient
Example #3: Deductible Not Waived Procedure – 2 Procedures
- Insurance plan setup:
- $50 individual deductible
- $2000 annual benefit
- Deductible not waived on Restorative procedures
- Restorative procedures covered 80%
- D2950 – Core Buildup Including Pins = Restorative procedure
- D2950 Fee = $200
- D2740 – Crown Porcln/Cer Substrate = Restorative procedure
- D2740 Fee = $1200
- Total Fees = $1400 ($200 + $1200)
- Estimated insurance = $1080 ($120 + $960)
- Estimated patient = $320 ($80 + $240)
- Calculation – D2950:
- $200 fee - $50 deductible = $150
- $150 x 80% = $120 estimated insurance
- $200 fee - $120 estimated insurance = $80 estimated patient
- Calculation – D2740:
- $1200 fee - $0 remaining deductible = $1200
- $1200 x 80% = $960 estimated insurance
- $1200 fee - $960 estimated insurance = $240 estimated patient