Deductibles, Premiums, Coinsurance, and Copayments
Dental insurance covers many procedures for patients. It benefits dentists since they could attract patients in their insurance networks. Though, patients and dentists must be aware of premiums, deductibles, copayments, and coinsurance.
Patients must pay premiums and deductibles to utilize their benefits. Premium “is the [often monthly] base fee charged by a dental plan” (DentalInsurance.com 2010c). Patients pay for lower premiums in dental PPO and HMO plans than fee for service dental plans (DentalInsurance.com 2010c). A deductible refers to the amount a patient “must pay for dental work before the plan kicks in to help” (DentalInsurance.com 2010b). They “may be charged by the year or on a one-time basis… not all dental plans have one” (DentalInsurance.com 2010b). Additionally, according to Delta Dental, a company that provides “dental benefits coverage,” “[when] your dentist submits a claim for a service (such as a filling), any applicable deductible is added to your coinsurance level. It may take more than one service or visit to satisfy the entire deductible” (“Deductibles”). Dr. Rick Farnsworth, “D.D.S. of Pro Solutions Dental Group Family, Implant & Restorative Dentistry – Offices of Jason C Campbell, DDS, Cosmetic & Family Dentistry,” states that a deductible “is on average $50 annually for an in-network dental care provider” (2017). A family deductible refers to a payment for which the whole family must pay, instead of each family member paying for their own deductible (DentalInsurance.com 2010b). Due to these scheduled payments, patients should utilize their plans’ benefits every year (Farnsworth 2017).
Regarding out-of-pocket payments, patients must pay coinsurance and copayments. Coinsurance refers to how “the beneficiary shares in the cost of covered services, generally on a percentage basis… Percentages vary and may apply to table of allowance plans; usual, customary, and reasonable plans; and direct reimbursement programs” (DentalInsurance.com 2014). For instance, if a patient’s dental insurance plan pays 80% for a particular treatment’s fee, then he or she pays a coinsurance of 20% (DentalInsurance.com 2010a). More PPO plans contain coinsurance rules than HMO plans (DentalInsurance.com 2010a). Copayment refers to “[a] fixed dollar amount that an enrollee under certain dental plans (such as a DHMO-type plan) is required to pay at the time the service is rendered” (“Insurance Terms”). Clinics commit fraud when they waive patients’ coinsurance and copayments (“Beware of offers to waive coinsurance/copayment amounts”).
The amounts of these payments vary between different insurance plans and clinics. DentalInsurance.com, “A leading provider of dental insurance,” states, “As a rule, other costs will have an effect on the plan’s premium. The higher the other costs are, the lower the premium will be” (2010c). In addition, lower premiums mean higher coinsurance payments (DentalInsurance.com 2010a). Clinics could also raise the costs of their treatments and services annually to factor in the “increased cost of living, materials and equipment,” potentially resulting in higher copayments (Farnsworth 2017). Consequently, Farnsworth recommends that patients should “[use their] benefits before the year end” (2017).
Patients and dentists must know these terms in order to follow the rules of dental insurance.