MetLife, a leading provider of dental coverage, uses three main cost-sharing components to structure its plans: copays, deductibles, and coinsurance. Because each component plays a distinct role in determining how much you pay out of pocket for dental services, understanding the differences between them can help you better plan and budget for dental expenses.
Copayments (Copays)
A copayment, often called a copay, is a fixed dollar amount you pay for a covered dental service at the time of your appointment. Copays are most common for basic services, and payment is usually required at the time you receive the treatment. Regardless of the total cost charged by the dentist, your copay remains the same, offering a level of predictability in your out-of-pocket spending.
In many cases, copays do not count toward your deductible, but they do contribute toward your annual out-of-pocket maximum.
Deductibles
A deductible is the amount you must pay out-of-pocket for services before your insurance begins sharing the costs. For instance, if your dental plan has a $500 deductible, you must pay the first $500 in covered dental expenses each year yourself. Only after reaching this threshold does the insurer start paying a share.
Notably, many MetLife plans waive the deductible for preventive services like cleanings, exams, and X-rays, which are often fully covered from day one to encourage regular dental visits and early detection of issues. For restorative services such as fillings, crowns, and root canals, though, the deductible typically applies.
Coinsurance
Coinsurance is the percentage of the service cost that you are responsible for paying, while the insurance company pays the rest. Unlike copays, which are fixed amounts, coinsurance is a variable amount based on the cost of the service. This means that for higher-cost treatments, your coinsurance payments can be substantial. For example, if you have a 20% coinsurance rate and the procedure costs $1,000, you would pay $200, and your insurance would cover the remaining $800.
It’s important to review your plan details so you understand the coinsurance rates for different types of dental procedures.
Out-of-Pocket Maximum
The out-of-pocket maximum is the limit on the total amount you have to pay for covered services in a plan year. Once you reach this amount, your insurance will pay 100% for any covered expenses for the remainder of the year. Premiums, the regular payments you make to keep your insurance active, do not count toward your out-of-pocket maximum. Still, understanding your maximum can help you estimate your worst-case financial exposure in any given year.
How They Work Together
In practice, copays, deductibles, and coinsurance interact dynamically. Initially, you will pay out-of-pocket costs toward your deductible. After that, you will share costs with the insurer through coinsurance. As you continue to pay these costs, they accumulate toward your out-of-pocket maximum, offering a safeguard against runaway expenses.
Dental insurance is designed to make oral health care more accessible and affordable, but understanding the key financial terms is critical. Clear knowledge of the component parts of a dental plan empowers you to maximize your benefits and maintain good dental health with greater financial confidence.
To learn more about coverage and treatments, contact us.