Ameritas Copays, Deductibles, and Coinsurance Definitions
Ameritas makes it simple and easy for you to understand and use your dental benefits. The answers to these frequently asked questions will help get you started.
Using your Ameritas dental insurance plan may be easier when you are familiar with common terms and what they mean. It will also make it easier to manage your costs when you understand what the cost terms will mean to your wallet. Here are the differences between copays, coinsurance, and out-of-pocket maximums.
What is Copay?
A copay, or copayment, is a fixed amount you will be expected to pay for a covered dental service, usually at the time of the treatment service. How does the copay work? You might remember when you went in for a doctor’s visit and paid $20 or $25 when finished. Copay amounts vary depending on both the provider and the treatment. With dental plans that have copays, not all do, you will know exactly what you will pay ahead of the appointment, which helps you budget your health care costs. For some plans, your copay does not apply toward your deductible. Some services might be covered at no additional cost, like an annual wellness exam and other preventive care services.
What is Coinsurance?
Coinsurance means a percentage of the cost of a service. Until you reach your plan’s deductible amount, you will pay 100% of any out-of-pocket costs. Once you have met your annual deductible, you and the insurance company each pay a designated share of the costs, which add up to the total. Common coinsurance ranges from 20% to 40% for you, with your plan paying the balance. But cost-sharing percentages vary depending on your plan. How does this coinsurance work? If your dental visit costs $100 and you have met your deductible, your coinsurance payment of 20% would be $20 out of pocket. Your insurance plan would then pay the balance of the allowed amount, or $80. Coinsurance does not apply until after you have reached your deductible.
What is an Out-of-Pocket Maximum or Limit
You have heard terms like out-of-pocket maximum or limit. They mean the same thing. Your out-of-pocket maximum or limit is the highest amount you will pay during an annual coverage period for your share of any costs. Usually, copays, deductibles, and coinsurance all add up to reach your out-of-pocket maximum. Your monthly premium, balance charges, or anything your plan does not cover, such as out-of-network costs, do not contribute to your out-of-pocket.
For example, if the dental charge is $100 and the allowed amount is $70, the dental office might bill you for the remaining $30. A preferred provider might not balance bill you for the services covered.
How Does an Out-of-Pocket Maximum Work
Once you reach your out-of-pocket maximum, your plan often pays 100% of your covered dental costs, up to the allowed amount. Let us say your plan has an annual out-of-pocket maximum of $6,000. This means once you have paid $6,000 out of pocket in that year for your covered dental care, usually including deductibles, copays, and coinsurance, your plan will then cover any future, covered, in-network, oral care services during the coverage period. If your dentist charges more than the plan's negotiated rate amount, you may have to pay the difference, or balance-billed charge.
Reach out to learn more about the insurance options we offer.