Sun Life makes it simple and easy for you to both understand and use your dental benefits. The following definitions will help determine what is best for you.
Using your Sun Life dental insurance plan will be even easier once you are familiar with common industry terms and their meanings. It will also make it easier to control your costs when you understand what the specific charges will mean for your budget. The following are some differences between your copays, coinsurance, and your out-of-pocket maximums.
What is Copay?
A copayment, or copay, is a fixed amount you pay for a covered dental service at the time of treatment. Here is how your copay works. Remember when you went in for a doctor’s visit and paid $20 or $25 upon completion? Copays vary depending on both the provider and the treatment. With a Sun Life dental plan that has a copay, you will know the exact amount before your appointment, which helps you budget your overall health care costs. For some dental plans, your copay might not apply toward your deductible. Some services might be covered for no additional cost, such as an annual wellness exam or other preventive care services.
What is Coinsurance?
Coinsurance simply means a cost percentage of a dental service. Until you reach your plan’s specific deductible amount, you could pay 100% of any out-of-pocket expenses. Once you have met your annual deductible, you and Sun Life will 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 Sun Life dental plan paying the balance. But cost-sharing percentages vary depending on your specific plan. How does coinsurance work? If your dental visit costs $100 and you have already met your annual deductible, your coinsurance payment of 20% would then be $20. Your Sun Life insurance plan pays the balance, or $80. Coinsurance is applied after you have reached your deductible.
What is an Out-of-Pocket Maximum or Limit
You have heard of insurance terms like out-of-pocket maximum or limit. They mean the same thing. Your out-of-pocket maximum or limit states the highest amount you will pay during your coverage period for your share of any costs. Most often, copays, deductibles, and coinsurance all add up to reach your out-of-pocket maximum. Your monthly premium, any balance charges, or anything else your plan does not cover, like out-of-network costs, will not contribute to your out-of-pocket maximum.
For example, if the treatment charge is $100 and your plan’s 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
After you have reached your out-of-pocket maximum, your plan may pay 100% of your covered dental costs, up to an allowed amount. For example, your specific Sun Life dental plan has an annual out-of-pocket maximum of $6,000. This means once you have paid $6,000 in out-of-pocket costs in that year for your covered dental care, typically including deductibles, copays, and coinsurance, your plan will then cover any future, covered, in-network, dental services during the period. If your dentist charges more than the negotiated rate in your plan, you may have to pay the difference, or a balance-billed charge.
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