Ameritas Copays, Deductibles, and Coinsurance Definitions
Ameritas makes it both easy and simple for you to understand and use your dental benefits. The following definitions will help get you started.
Using your Ameritas dental insurance plan will be even easier when you are familiar with common industry terms and what they mean. It will also make it easier to manage your costs when you understand what the specific costs will mean for your wallet. Here are some differences between your copays, coinsurance, and out-of-pocket maximums.
What is Copay?
A copayment, or copay, is a fixed amount you will need to pay for a covered dental service at the time of the treatment. How does your copay work? You may remember when you went in for a doctor’s visit and paid $20 or $25 upon completion. Copays will vary depending on the provider and the treatment. With a dental plan that has a copay, you will know exactly what you will pay ahead of your appointment, which then helps you budget your overall health care costs. For some dental plans, your copay will not apply toward your deductible. Some services may be covered for 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 dental service. Until you reach your plan’s deductible amount, you pay 100% of any out-of-pocket expenses. Once you have met this annual deductible, you and your insurance company will each pay a designated share of the costs, which add up to the total. Usual coinsurance ranges from 20% to 40% for you, with your dental plan paying the balance. But cost-sharing percentages will vary depending on your specific plan. How does coinsurance work? If your dental visit costs $100 and you have met your annual deductible, your coinsurance payment of 20% would be $20 out of your pocket. Your insurance plan pays the balance of the allowed amount, or $80. Coinsurance is not applicable until you have reached your deductible.
What is an Out-of-Pocket Maximum or Limit
You have heard of terms like out-of-pocket maximum or limit. They actually mean the same thing. Your out-of-pocket maximum or limit reflects the highest amount you will pay during the coverage period for your share of any costs. Usually, copays, deductibles, and coinsurance add up to reach your out-of-pocket maximum. Your monthly premium, any balance charges, or anything your plan will not cover, such as out-of-network costs, will not contribute to your out-of-pocket.
As an example, if the dental charge is $100 and the plan allowed amount is $70, the dental office could bill you for the remaining $30. A preferred provider may not balance bill you for the services covered.
How Does an Out-of-Pocket Maximum Work
Once you have reached your out-of-pocket maximum, your plan often pays 100% of your covered dental costs, up to the allowed amount. For example, let us say your plan has an annual out-of-pocket maximum of $6,000. This means that once you have paid $6,000 in out-of-pocket costs in that plan year for your covered dental care, usually including deductibles, copays, and coinsurance, your plan then covers any future, covered, in-network, dental services during the period. If the dentist charges more than the negotiated rate amount in your plan, you might have to pay the difference, or a balance-billed charge.
Learn about our financing and insurance options.