1. How much will insurance pay for sleep apnea oral appliance therapy?
This depends on a number of factors including: allowable amount; billed amount; deductible and co-insurance. For illustration purposes, let's use these amounts:
Billed amount for the oral appliance: $ 3,500
Deductible: $ 1,000; amount met: $ 350
Out of pocket maximum: $ 5,000
The allowable amount is determined by the health insurance plan at the time the claim is processed, for out of network claims. If a practice is contracted as an in-network provider, they can determine the contracted allowable amount for the service in advance. However, most dental practices are non-contracted providers, so the allowable amount will not be available until the claim is processed.
For the above example, if the insurance company allows $ 3,000 for the appliance, the allowable amount will be $ 3,000. To this, the remaining deductible of $ 650 will be applied. The co-insurance amount on this plan is 80%, so of the $ 2,350, the plan will pay 80% (or $ 1,880) and apply 20% (or $ 470) to the co-insurance amount that will be the patient's financial responsibility.
In this case, the plan will pay $ 1,880 and the patient will be responsible for the remaining deductible of $ 650; the co-insurance in the amount of $ 470, and the $ 500 which is over the allowable amount as determined by the insurance plan.