Estimating Insurance for DMO/Capitation Plans

The following table explains the insurance estimation calculations used for dental and medical DMO/Capitation plans. The calculations show the estimations when the deductible is subtracted first or last.

The calculations are based upon the following example: The fee is $88, the allowed amount is $75, the bluebook insurance payment is $60, the coverage is 80%, the copayment is $30, and the deductible is $25.

The insurance estimation calculations used for dental and medical DMO/Capitation plans are:

Plan Type

Calculations

Dental DMO/Capitation Plan

Bluebook Entry

No Deductible

The estimated insurance payment equals the insurance payment entered in the bluebook.

In the example:In the example:The estimated insurance payment is $60.

Dental DMO/Capitation Plan

Bluebook Entry

Deductible Subtracted First

The deductible is automatically subtracted from the estimated insurance payment entered in the bluebook.

In the example:In the example:The $25 deductible amount is subtracted from the $60. The estimated insurance payment is $35.

Dental DMO/Capitation Plan

Bluebook Entry

Deductible Subtracted Last

The deductible is automatically subtracted from the estimated insurance payment entered in the bluebook.

In the example:In the example:The $25 deductible amount is subtracted from the $60. The estimated insurance payment is $35.

Dental DMO/Capitation Plan

No Bluebook Entry

No Deductible

The copay is automatically subtracted from the fee.

In the example:In the example:The $30 copay is subtracted from the $88 fee. The estimated insurance payment is $58.

Dental DMO/Capitation Plan

No Bluebook Entry

Deductible Subtracted First

The copay is automatically subtracted from the fee. The $25 deductible is subtracted from the difference.

In the example:In the example:The $30 copay is subtracted from the $88 fee, leaving $58. The $25 deductible is subtracted from $58. The estimated insurance payment is $33.

Dental DMO/Capitation Plan

No Bluebook Entry

Deductible Subtracted Last

The copay is automatically subtracted from the fee. The $25 deductible is subtracted from the difference.

In the example:In the example:The $30 copay is subtracted from the $88 fee, leaving $58. The $25 deductible is subtracted from $58. The estimated insurance payment is $33.

Medical v/Capitation Plan

Bluebook Entry

Deductibles Do Not Apply

The estimated insurance payment equals the insurance payment entered in the bluebook.

In the example:In the example:The estimated insurance payment is $60.

Medical DMO/Capitation Plan

No Bluebook Entry

Deductibles Do Not Apply

The copay is automatically subtracted from the fee.

In the example:In the example:The $30 copay is subtracted from the $88 fee. The estimated insurance payment is $58.