The dollar amount you pay each year before your insurance will begin paying. This amount depends upon your company and your individual plan.
Your “co-payment” is the dollar amount you pay each time you receive a specified dental care service up to the yearly “maximum allowable limit” of your plan. After you reach your plan’s yearly “maximum coverage”, you are responsible for 100% payment of additional care you might seek for the remainder of the year.
Your “out of pocket” expense is determined by the amount you pay per calendar year in deductibles and co-pays before your insurance begins paying at the specified contract percentage for any given procedure(s) be it 80%, 50%, etc. If you exceed your plan’s yearly maximum benefit your “out of pocket” expenses will then increase because you will then be 100% responsible for the cost of any further dental care.
The “Usual and Customary” Fee Schedule your insurance company refers to is the fee schedule that has been pre-determined by your employer’s negotiations with the insurance company they have contracted with. This fee schedule represents the maximum dollar amount (UCR) for every fee that your insurance company has contracted with your employer as to what is a “covered” procedure under your plan.
The insurance “Usual and Customary” Fee Schedule (UCR) is NOT the same as your dental care provider’s fee schedule for procedures. Dental care providers determine their own individual fee schedules. Therefore, your dental care provider will bill you for the difference between your insurance company’s “Maximum Allowable Fee” dollar amount and your care provider’s total dollar value for any given procedure. Most dental care providers will “accept” your dental insurance.