When reviewing dental and vision insurance options, one of the most common questions we hear is:

“What happens if I go out-of-network?”

The answer depends on the type of plan you have—and for dental, it depends on how the carrier structures reimbursement.

Let’s break it down in a simple way.

Dental Plans: UCR vs. MAC (And Why It Matters)

Dental plans typically reimburse out-of-network care in one of two ways:

• UCR (Usual, Customary, and Reasonable)

• MAC (Maximum Allowable Charge)

You will usually see plans from carriers like Beam Dental or Humana using one of these methods.

UCR (Usual, Customary, and Reasonable)

UCR is generally the more generous of the two approaches.

• The insurance company looks at what dentists in your area typically charge

• They set a “reasonable” amount based on that data (often at the 90th percentile)

• The plan then pays a percentage of that amount (for example, 80%)

What this means for you:

• Higher reimbursement potential

• Lower out-of-pocket costs (in many cases)

• Still some variability depending on the carrier’s internal data

MAC (Maximum Allowable Charge)

MAC is a fixed fee schedule set by the insurance company.

• Each procedure has a predefined dollar amount

• The plan pays a percentage of that set amount—regardless of what dentists in your area charge

What this means for you:

• More predictable reimbursement amounts

• But often lower than UCR-based reimbursements

• Potentially higher out-of-pocket costs if your provider charges more than the MAC limit

Simple Comparison

UCR Plans

• Based on local market rates

• Typically higher reimbursement

• More favorable for out-of-network care

MAC Plans

• Based on a fixed internal fee schedule

• Often lower reimbursement

• Greater potential for balance billing

Vision Plans: Fixed Dollar Reimbursement

Vision plans—like those from VSP, EyeMed, or Humana—work differently than dental.

They do not use UCR or MAC.

Instead, they provide a set reimbursement amount for out-of-network services.

For example:

• Eye exam: reimbursed up to a fixed amount

• Frames: reimbursed up to a set allowance

• Lenses: reimbursed based on a schedule

What this means for you:

• Simple and predictable

• But capped—if your provider charges more, you pay the difference

Key Differences at a Glance

Dental Plans

• Use UCR or MAC

• Pay a percentage of an allowed amount

• UCR is typically more favorable than MAC

Vision Plans

• Use a fixed reimbursement schedule

• Pay up to a set dollar amount

• Easy to understand, but more limited out-of-network

Our Recommendation

Whenever possible, staying in-network will give you the best value.

However, if you prefer to see a specific provider:

• A UCR dental plan will usually provide stronger out-of-network coverage

• A MAC dental plan may result in higher out-of-pocket costs

• Vision plans will reimburse you up to a fixed amount, so you can plan accordingly

Final Thoughts

Not all out-of-network benefits are created equal.

Understanding whether your dental plan uses UCR or MAC can make a meaningful difference in what you actually pay and helps avoid surprises when receiving care.