Insurance Plans Part 2: Complex Plan Types


As insurance plans continue to evolve, you may encounter plans that require different setup options. In Part 1 of this series, we covered Common Plan Types. This Part 2 post discusses more complex plan types including Capitation and Medicaid/Flat Co-pay plans. By following our guide below, you can ensure more accurate insurance estimates for patients and improve your reporting accuracy.


Capitation plans, also known as HMO or DMO plans, are used when insurance pays a flat monthly fee, regardless of what procedures are performed on the patient. The setup for capitation plans varies depending on how the insurance handles procedures.

To explore capitation plan setup options and tips on capitation fee schedules, see our Decision Making Guide!

If a capitation plan only pays a monthly flat fee, you never bill insurance, and you do not receive payments for specific procedures, then set the insurance plan type to Capitation. This will zero out the benefit coverage, and calculate estimates using the capitation fee schedule.

insurance plan

If a capitation plan pays a flat monthly fee and you bill insurance for specific procedures (like crowns), then set the insurance plan type to PPO Percentage. Be sure to set the insurance benefits to cover at 100%. This will ensure the fees are covered using the capitation fee schedule and give more accurate estimates.

insurance plan

insurance plan

To easily handle monthly capitation payments, we recommend the following:

  1. Create a dummy patient using the name of the insurance carrier. All payments will be applied to this patient.
  2. Add the capitation insurance plan to the dummy patient.
  3. Create a custom dummy procedure code for the monthly capitation payment.
  4. Chart and set complete the dummy procedure code, then create a claim, and click OK.
  5. Apply the capitation payment to the claim that was just created, then immediately finalize the payment by clicking “This Claim Only”.

For each monthly payment, repeat steps 4 and 5. This setup keeps all of your capitation payments in one easy spot for each carrier. By creating and receiving claims this way, payments can be tracked and reported on as needed.

If you are billing out a procedure to a capitation insurance plan, chart the procedure on the patient. Once complete, send the claim and receive the payment as you normally would.


Medicaid / Flat Co-Pay

Medicaid and Flat Co-Pay plans are set up the same way in Open Dental.

Set the Plan Type to Medicaid or Flat Co-Pay. This will zero out the benefit coverage, and pay 100% of the attached fee schedule.

Fee Schedules

The fee schedule you get from insurance may be the full fee you are able to collect, or it may just be what they are going to pay you. Be sure to set this up properly in Open Dental for the most accurate estimates.

If the insurance fee schedule is the total amount you are allowed to collect (including patient co-pay amounts):

  1. Create the patient co-pay fee schedule.
  2. Create the insurance fee schedule using the amounts provided by the carrier.

If the insurance fee schedule is the amount insurance is paying you (and patient co-pay is not included in the amount):

  1. Create the patient co-pay fee schedule.
  2. Create the insurance fee schedule by taking the insurance amount and adding the co-pay amount.
    (e.g. if the insurance will pay $100, and the patient co-pay is $50, the fee schedule amount should show $150)

Assigning the correct plan type is especially important for complex plans. With proper setup, benefit and copay amounts will calculate correctly, ensuring the accuracy of your patient accounts, and allowing reporting on carrier payments.

Don’t miss Insurance Plans Part 1: Common Plan Types

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