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Understand How Copays, Deductibles, And Coinsurance Work

dental insurance

A major part of having dental insurance is the cost sharing or out-of-pocket expenses that all insurance providers require patients to meet. Along with the premiums, members are also responsible for the copays, deductibles and coinsurance. Understanding how they are applied is vital for patients to plan their annual dental insurance costs. As a dental practitioner, one additional step that you can take to enhance patient experience is to educate them about their out-of-pocket expenses.

Deductible

Dental plans require that patients first pay for their dental services up to a fixed amount before the insurance provider starts paying for their covered services. This fixed amount resets annually and is called a deductible. Patients are completely responsible for their dental care expenses until they reach their deductible amount. However, preventive care, such as checkups, X-rays, and cleanings, are typically covered in full by the insurance plan. So, say your patient’s plan has an annual deductible of $100. If your patient comes in for a routine cleaning, the service may be covered in full by the insurance provider even if the deductible amount has not been met for that year. Some plans also have separate deductible amounts depending on whether you, as a dental rcm provider, are within network or out of network. 

Key points to note about deductibles:

  • Deductibles may not apply to all services
  • Separate deductibles apply to specific services under some plans.
  • Family plans typically have both an individual deductible that is applicable to each member of the family and a family deductible. 

Copay

Simply put, a copay or copayment is a fixed fee that your patient pays for each visit of specific covered services. Copays may not apply to all covered services and may vary depending on what service the patient comes in for. The amount also remains the same regardless of the final bill that you as the dental provider raise. A patient could have a $10 copay for a routine check up, no copays for cleaning and a $150 copay for emergency visits. Let’s say your patient has had two dental emergency visits with you during a policy year. The cost for each visit may be different. However, your patient would have to pay $150 as the copay for each of the emergency visits. The remaining is paid by the insurance provider. Copays typically apply even if the patient has met their annual deductible. Copayment amounts could change depending on your network status with their insurance provider. 

Coinsurance

Coinsurance is a percentage that your patient pays for dental services once their annual deductible has been met. The remaining amount is paid by the insurance provider. If the coinsurance percentage for your patient’s plan is set at 20%, the remaining 80% would be paid by the insurance provider. Coinsurance percentages may vary depending on the services the patient receives. Amounts could also vary depending on whether you are within network or out of network with their insurance provider. 

How it works

Out-of-pocket expenses and other charges may vary depending on the dental insurance provider. Typically, patients pay their premiums to have dental insurance. Each time your patient visits, they may pay a copay, which may or may not add to their annual deductible amount. Once the deductible amount is met for that year, the coinsurance percentage that the patient needs to pay, kicks in. The copay and coinsurance amounts need to be paid till the out-of-pocket maximum for that particular year has been met. The insurance provider then typically pays 100% of all the charges till the annual maximum is met or till the policy year ends. 

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