A co-payment is the portion of the bill that the insurance company determines to be your responsibility. It’s the most common way for dental plans to limit their costs, thereby providing various plans with an assortment of benefits and price points for the purchaser to choose from. Some plans also take other approaches to limit plan spending, including setting annual deductibles, capping the dollar amount or limiting the number of visits covered within a year.
That depends on your plan. An 80/20 co-payment is common for basic procedures such as fillings and root canals. This means that the dental plan covers 80% of the bill. A 50/50 co-payment is common for major procedures such as crowns and bridges. However, there are many variations, be sure to check your specific plan.
No. The waiving of a co-payment is considered insurance fraud. When you and your dentist sign the claim form that gets submitted to the insurance company, you are stating which services were provided and how much, in total, was charged. The insurance company pays its share based on the assumption that you will do the same.
“Indemnity” or “Traditional” insurance reimburses subscribers (or dentists) at the dentist’s UCR (Usual, Customary & Reasonable fee). This allows the subscriber to go to any dental office without being limited to dentists who are specifically contracted with the insurance company.
PPO (Preferred Provider Organization) is the most common form of dental insurance. These plans provide subscribers with a list of participating (also known as “in-network”) dentists from which to choose. The nice aspect of a PPO plan is that you are free to choose your dentist regardless of their network status. The dentists on this list have agreed to a lowered fee schedule, which provides the subscriber with a lower copayment.
HMO, also known as “capitated” or prepaid insurance, was designed to provide subscribers with very basic care at the lowest rate. Patients must first choose their dentist from the list of participating providers and then they are assigned to that specific office. HMO plans may not pay for services rendered. Fees are usually greatly reduced, but the patient is responsible for paying the doctor. Discount Plans simply consist of a list of dentists who have agreed in advance to accept a reduced fee schedule, with the subscriber being solely responsible for the entire fee at the time the service is rendered. There are no claims to file or annual maximum limits of coverage.
Treatment that is recommended by a dentist, is listed on the insurance plan fee schedule and accepted under the terms of subscriber’s insurance plan.
There are thousands of types of dental insurance plans. It all depends what type of plan your employer purchases and what benefits are included. We do our best to help you understand and work with your insurance policy, find out the allowed annual maximum, any deductibles and eligibility for services. We will also submit all insurance claims for you and willfully attempt to help you receive full insurance benefits. However, you are ultimately personally responsible for your account. Please remember that an insurance policy is a contract between you, your employer and the insurance company, not us.
Because policies can change every year when contracts renew, often without clear communication, we encourage our patients to become familiar with their insurance coverage. We also recommend our patients take the time and understand which policy they are selecting during the Open Enrollment period. Changes in eligibility, maximums, or benefits could result in unexpected out of pocket costs. Ultimately, all charges for services are your financial responsibility should the insurance company not pay.