Have you ever worked at a job where you were allowed to pick a benefit plan that fits your needs?
I have…and at first, it was was exciting. But after looking at all the different packages, it made no sense to me. This was stressful because it can be detrimental to make a mistake on such an important decision. When your finances and your health are at stake, making the right decision is important.
Insurance can be confusing, like coinsurance vs. copay. Understanding these terms along with the other complicated components of insurance can be stressful. After speaking to Sharon Kay Smith, a Clinical Review Specialist with DDCO, and Irina Nekhenzon, a Clinical System Support Specialist with DDCO, they helped take the jargon out of insurance and break down coinsurance vs. copay.
Coinsurance
Coinsurance is the percent of a covered amount that the provider will pay for after you have paid your deductible. The coinsurance varies depending on the company, the provider, the type of service and the type of network.
Since coinsurance has so many variables, it is different for everyone across the health insurance spectrum. Here are a couple of examples:
- Let’s say your dental insurance plan’s allowed amount for a crown is $100 and your coinsurance is 20%. If you’ve paid your deductible: You pay 20% of $100, or $20.
- Still confused? Think about coinsurance like splitting the check with your friends. Coinsurance is how you break down the check. When 2 couples share the check 50/50, then your “coinsurance” on the check is 50%.
Coinsurance differs depending on the type of procedure that is being performed. According to Sharon Smith and Irina Nekhenzon, the typical percentage covered in Delta Dentals network is:
- 100%: Routine preventive and diagnostic care such as teeth cleanings and traditional dental exams.
- 80%: Basic procedures such as fillings, cavities, tooth extractions, root canals.
- 50%: Major procedures such as crowns, implants, bridges and bone graphs.
Copay
A copay is the amount of percentage of the total approved amount that the subscriber is obligated to pay for the service.
- For example, let’s say that your health insurance plan’s copay is $20 for normal services and $40 for special care. If you go to see your primary care physician, then your copay is $20, which you pay upon arrival at the doctor’s office. Any costs above your copay amount are handled at your coinsurance coverage rate.
- Still scratching your head? Here’s an example. You may have a $25 copay every time you see your primary care physician, a $10 copay for each monthly prescription or medication and a $250 copay for an emergency room visit.
- Still confused? In other words, a copay is a predetermined rate that you pay for at the time of your health care service. Copays can vary for different services within the same plan, and prices range based on what your network covers and if the service is routine or more complicated and expensive.
Dental benefits: A lot of dental insurance plans do not have copays for preventive and diagnostic care. Boom, instant savings!
Click here to check out Delta Dentals Glossary of Dental Terms!
Important note: Coinsurance and copays are your only out-of-pocket costs once you meet your deductible unless you’ve reached your annual maximum. But remember that costs and levels on the 2 items vary based on your plan’s design. Make sure to log on and find the details of your coverage. And if you need help understanding how your coverage applies to the care you need, use our cost estimator. And check out our blog to understand an explanation of your benefits or visit our website for more information!
*Updated 2019