National Care | Compliance: PPO vs. Non-PPO

September 22, 2020

Product knowledge is not only a key factor for compliance, it is also a key factor for customer retention!

Most agents spend a lot of time and effort in reviewing products with potential customers and conducting enrollment. Giving a customer incomplete or incorrect information will most likely result in that customer canceling the plan you enrolled them in. That cancellation can sometimes result in a refund of premiums which can then result in a loss of commission for the agent. It could also result in the customer filing a complaint with National Care Dental or with a state regulatory agency. Losing a customer is not the desired result for the enrolling agent or for National Care Dental.

Featured Topic: PPO Dental Provider (In-Network) vs. Non-PPO Dental Provider (Out-of-Network)

The National Care dental plan, underwritten by Nationwide Insurance Company, is a Preferred Provider Plan (PPO) that pays based on Maximum Allowable Charges (MAC).

The dental plan uses Maximum Care PPO which includes preferred provider networks Careington, Connection Dental, and DenteMax.

The National Care Dental plan does give the member the choice of using either an in-network provider or an out-of-network provider. However, it is your responsibility as their agent, to make sure that the member understands that they may have to pay more out-of-pocket if they use an out-of-network provider.

  • In-network providers are dental providers that have chosen to contract with Maximum Care PPO. The providers agree to accept a PPO contracted fee schedule as the maximum allowable charges (MAC), and agree to write off the difference between their standard bill rates and the MAC. The dental provider cannot charge the member any additional out-of-pocket expenses for services covered under the dental plan. The member will only be responsible for any remaining deductible, co-pay, or non-covered services.
  • Out-of-network providers are dental providers that are not contracted with Maximum Care PPO. These dental providers will bill the member at their own bill rates, which are normally higher than the MAC. The insurance company will pay the dental provider based on the MAC. The patient will be responsible for paying the dental provider for the difference between the dental provider bill rates and the MAC, in addition to any remaining deductible, co-pay, or non-covered services.

By sharing your knowledge with the member, you will have a happy member which will be much more likely to keep paying for their dental plan, and maybe even get you some referrals!

For more information, contact a Pinnacle Financial Services representative today

1 (800) 772-6881 x7731 | sales@pfsinsurance.com

Contact a Pinnacle Representative if you have any questions.

1 (800) 772-6881


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