Understanding Co-payment

What is co-payment?

Co-payment—also called co-insurance—is the portion of the bill that is your own 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.

Some plans are also taking other approaches to limit plan spending: setting annual deductibles, capping the dollar amount or limiting the number of visits covered within a year.

How much do I have to pay?

That depends on your plan.

An 80/20 co-payment is common for basic procedures such as x-rays, cleaning, 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.

But there are many variations; be sure to check your specific plan.

Can my dentist waive my co-payment?

No. The waiving of a co-payment is insurance fraud and is against the law. Your dentist could be heavily fined or even lose their license.

When you and your dentist sign the claim form that goes 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 upon the assumption that you will do the same.

Understanding Your Policy Fee Guide

Each insurance company has it’s own fee guide policy. Your dentist does not follow these fee guides because many insurance companies may have multiple fee guides and it is not practical to follow each and every one of them. Just because a policy from your insurance company may indicate 100% coverage, that may not cover the complete costs that the dentist office may have. This means that you may have to pay a balance over and above the value of your insurance coverage due to this difference.

from the Canadian Dental Association, Inc.

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