Insurance is unnecessarily complicated. A good example is how Anthem Blue Cross of California names its small business dental plans. Here are a few of the dental plan names:

  • Bronze PPO 100/80/50 Active 50/Unlimited MAC E&P Basic CH Ortho
  • Silver PPO 100/80/50 Passive 50/1500 90th E&P Basic CH Ortho

Anthem Blue Cross of California small group dental plans offer very good benefits, and they include many dentists. They are also well-priced. You should consider these dental plans for your employees. For some reason, however, Anthem does a terrible job communicating the benefits of these plans to consumers. This article may help.

I’ve been in the insurance industry for nearly 30 years and I had no idea what the difference was between “active” and “passive,” or, what “E&P” meant. I know what “MAC” and “90th” refer to but most people have no clue what this means. It’s no wonder people feel frustrated with insurance companies. It’s especially frustrating because, unlike buying a car where a consumer can see different features of the product, insurance is intangible, and we must rely on the benefit descriptions to understand what we’re buying.

Guide to Understanding Anthem Blue Cross of California Insurance Terms

To help decipher this gobbledygook, I’ve written a guide to the confusing terms and abbreviations. Hopefully this will help you make sense of the plans and understand why one plan may be more or less expensive than another plan.

  • Bronze PPO 100/80/50 Active 50/Unlimited MAC E&P Basic CH Ortho
  • Silver PPO 100/80/50 Passive 50/1500 90th E&P Basic CH Ortho

“100/80/50” refers to the percentage the insurance company will pay for dental services. There are three categories of dental care:

  • Diagnostic & Preventive Services
  • Basic Services
  • Major Services

These three categories are the most common way that insurance companies split up dental services to pay dentists. So, a 100/80/50 plan will pay 100% of the negotiated cost for diagnostic and preventive services, such as exams, X-Rays, and teeth cleaning. It will pay 80% for basic services such as fillings (called “amalgams” in dental jargon), endodontics, which includes root canals, periodontics which is cleaning the root of a tooth, and other services. The plan will pay 50% of the cost for major “restorative” services like dentures, crowns, veneers, implants and other services.

  • Bronze PPO 100/80/50 Active 50/Unlimited MAC E&P Basic CH Ortho
  • Silver PPO 100/80/50 Passive 50/1500 90th E&P Basic CH Ortho

“Active” means that the percentage co-insurance for in-network and out-of-network (OON) dentists is different. For example, on an “Active” plan, Anthem will pay 80% for Basic services to in-network dentists but only pay 60% to OON dentists.

“Passive” means that the percentage co-insurance for in-network and out-of-network (OON) dentists is the same. For example, Anthem will pay 80% for Basic services or Endodontics to both in-network and OON dentists. This is better than “Active”.

  • Bronze PPO 100/80/50 Active 50/Unlimited MAC E&P Basic CH Ortho
  • Silver PPO 100/80/50 Passive 50/1500 90th E&P Basic CH Ortho

“50/Unlimited” means that there is a $50 deductible for dental services. Reading the fine print shows that Anthem “waives” or doesn’t charge the deductible for “diagnostic and preventive” services, such as exams and teeth cleaning. “Unlimited” means that there is no maximum amount the dental insurance plan will pay in a calendar year. This is a very good benefit for people who need a lot of dental work.

“50/1500” means that the plan has a $50 deductible – but that doesn’t apply to diagnostic and preventive services, see above. “1500” refers to the maximum the dental insurance plan will pay in a calendar year – not a plan year, which would begin when your plan begins or renews. So, on this plan the insurance company would pay a maximum of $1,500 in a calendar year (January – December) for dental services. Every January 1st, the maximum resets to zero used. A $1,500 maximum is a very common benefit in the small group market. Some plans have $1,000, $2,000, $2,500, or $3,000 calendar year maximums. The higher the maximum, the more the insurance company will pay.

  • Bronze PPO 100/80/50 Active 50/Unlimited MAC E&P Basic CH Ortho
  • Silver PPO 100/80/50 Passive 50/1500 90th E&P Basic CH Ortho

“MAC” stands for “Maximum Allowable Charge” which means that Anthem has a fee schedule. A fee schedule lists each dental procedure and the amount the insurance company will pay for that procedure. The insurance company will pay dentists for services based on the amount on the fee schedule. It doesn’t matter what the dentist charges, Anthem will only pay based on the amount on the fee schedule. This could be a problem if someone uses an out-of-network (OON) dentist (sorry for yet another abbreviation) because the OON dentist may charge a higher amount for a service but Anthem will only pay a percentage based on the lower MAC amount. The patient must pay the additional amount to the OON dentist. A better reimbursement design for people who use OON dentists is “Usual, Customary & Reasonable” or “UCR.”

“UCR” isn’t in the title, but it is an important part of the plans that say “90th”. UCR stands for “Usual, Customary & Reasonable.” According to the U.S. government site for Health Care, UCR is the amount an insurance company pays for a dental service in a geographic area. The amount is based on what other dentists in the area usually charge for the same dental procedure.

“90th” stands for the percentile of dentists who accept as full payment the amount an insurance company pays for a specific dental procedure. This percentile applies to plans that reimburse based on Usual, Customary & Reasonable charges. So, in this case, 90% of the dentists would accept the amount Anthem would pay for a dental procedure. This normally applies to out-of-network (OON) dentists because in-network dentists have agreed to limit the amount they charge for services by signing on to be an in-network dentist. “UCR 90th” is a better reimbursement plan design for people who use an out-of-network dentist. Accordingly, plans with “90th” cost more than “MAC” plans.

  • Bronze PPO 100/80/50 Active 50/Unlimited MAC E&P Basic CH Ortho
  • Silver PPO 100/80/50 Passive 50/1500 90th E&P Basic CH Ortho

“E&P Basic” means Endodontics & Periodontics and it refers to treatment of the gums and soft tissue in your mouth. As described above, insurance companies lump dental services into three categories: Preventative, Basic and Major. When Anthem puts “E&P Basic” in the title, they include these services in the “Basic” rather than “Major.” On most plans, Anthem pays a higher percentage for dental procedures that are in the Basic category. So, it’s better for you when “E&P Basic” is in the title because it means that the insurance company will pay more for endodontic and periodontic services.

  • Bronze PPO 100/80/50 Active 50/Unlimited MAC E&P Basic CH Ortho
  • Silver PPO 100/80/50 Passive 50/1500 90th E&P Basic CH Ortho

“CH Ortho” means that the dental plan covers orthodontia (i.e., braces) for children through age 18. If you’re an adult, this plan won’t cover braces for you. The dental benefit usually pays 50% of the cost up to a maximum of $1,500.

Hopefully, these definitions will help you better understand the confusing world of dental insurance. Remember that you can make Benefits Cafe the broker on your dental, medical and vision plans at no additional charge. Just give us a call at 800-746-0045 and we can discuss your needs.