Estimating Insurance for Medicaid Plans

The following table explains the insurance estimation calculations used for dental and medical flat fee Medicaid 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 for dental and medical flat fee Medicaid plans are:

Plan Type

Calculations

Dental Medicaid 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 Medicaid Plan

Bluebook Entry

Deductible Subtracted First

The deductible is automatically subtracted from the estimated insurance payment entered in the bluebook. The difference is added to the estimated write-off amount.

In the example:In the example:The $25 deductible amount is subtracted from the $60, leaving $35. The $35 difference is added to the $13 estimated write-off amount ($88 fee - $75 allowed amount). The estimated insurance payment is $48.

Dental Medicaid 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, leaving $35. The estimated insurance payment is $35.

Dental Medicaid 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 Medicaid 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 Medicaid 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 Medicaid 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 Medicaid 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.