Dental Insurance Copay
- Delta Dental Copays
- Principal Dental Insurance Copay
- Delta Dental Insurance Copay
- How To Calculate Dental Copay
- Dental Insurance Copay
A copay is a fixed amount you pay for a service, usually when you receive the service. When you have a Blue Dental plan, there are no copays for dental care. Whether or not you have to pay a deductible depends on the plan and the kind of dental care you get. But deductibles are very low compared to medical plans. See if any of our dental insurance plans are right for you. A UnitedHealthcare dental plan can provide the dental care you and your family need. Negotiated Fees refers to the fees that in-network dentists have agreed to accept as payment in full for covered services, subject to any co-pays, deductibles, cost sharing and benefits maximums. Negotiated fees are subject to change. 5 Those services defined under your dental benefits summary are covered. Please review your plan benefits. Dental insurance differs from health insurance in the following ways: Common preventive treatments – checkups, cleanings, and x-rays – are usually covered at 100% without out-of-pocket charges. The deductible is much lower than a medical plan – around $50 for an individual and $150 for a family. The right dental insurance can make dental care easy and affordable. Humana has individual coverage options for dental insurance that fit your needs. Alert Message: Visit our coronavirus resources page to get the latest information on COVID-19 and learn more about the new vaccines.
An article written with Dr. Sherry Tsai
You want healthy, beautiful smiles for everyone in your family, but will your dental insurance cover all the costs or just some? We understand that costs are important to you. It can be overwhelming to try to figure out what your dental insurance plan covers and what types of copays, if any, you'll need to pay yourself. This guide is to help you better understand your insurance plan. Though your specific details will differ, it allows you to have an idea of what your insurance will cover. Keep in mind, the only way to know for sure what your plan will cover is to submit a pre-authorization request. Please let us know if you would like us to submit for you.
Dental Insurance Coverage - The Different Treatment Classes
Though there are thousands of dental and medical codes that are used to properly bill treatments, there are a few basic code classes or types: Preventative, Endodontics, Minor or Basic Restorative, and Major Restorative. Preventative covers cleanings and basic exams as well as X-rays. Endodontics covers root canal treatments. Minor and Major Restoratives cover fillings, crowns, bridges, etc.
A typical dental insurance break down (coverage) will look like this:
»Preventative - 100% No Deductible - Cleanings, basic exams, etc.
»Endodontics - 80% $50 Deductible - Root canal therapy
»Basic/Extractions - 80% $50 Deductible - Fillings, extractions, etc
»Major Restorative - 50% $50 Deductible - Crowns, bridges, etc.
»Night Guards - 50% $50 Deductible - Guards to protect your teeth from grinding
»Ortho - $1,500 lifetime with no deductible - Braces, retainers, invisalign, etc.
Dental Insurance Coverage - In or Out of Network?
The key factor to understand about in or out of network is your insurance plan’s allowable fees. This typically means savings for you if you stay in-network. Dentists that are in-network have to honor the discounted insurance price. They are not allowed to charge you more for procedures than that amount which the contract states. In general patients will see a 20-50% savings when they visit a dentist in their network. Here is a simple example:
Out of Network Dental Office:
» Filling cost: $100
» Your allowable fee: $80
» Your coverage: 80%
» Your copay: Filling Cost - (allowable fee * 80%) = $36
In-Network Dental Office:
» Filling cost: $100 - No longer applies since you are in-network
» Your allowable fee: $80 (this is your contracted fee now)
» Your coverage: 80%
» Your copay: Allowable Fee * 20% = $16
In this situation, going to an in-network dentist saves you 55%!
So the basic calculation is as follows:
(Dentist’s Price - In-Network Adjustment or contract rate) * (1.0 - Percent Coverage) + Your Deductible
Dental Insurance Coverage - Deductibles
A dental insurance deductible is a sneaky way your employer or your insurance company uses to pass some of the upfront cost on to you. The simplest form of a deductible is the patient paying the first $50 of treatment.
After the first $50 of treatment, your insurance plan will start covering by their percentage. For example, if you have a $50 copay and 80% coverage on a $100 treatment, your copay would be:
$100 - $50 = $50
Insurance covers 80% of $50 = $40
> So your copay is: $100 - $40 = $60.
Once your deductible is paid (the first $50 in this example), you would only have to pay the 20% that the insurance company doesn’t pay.
This puts a little more of the cost of treatment on you at first. The “game” is to expend all your insurance you need to utilize in one calendar year. Because the deductible is usually annual (yearly), it resets each year. So, if you do a few fillings on year 1 and a few on year 2, you end up paying your deductible twice. Obviously, we can’t plan for all dental treatments; but, if we know that you need a few fillings or crowns, we suggest that you do them in the same year to save on the deductible.
Dental Insurance Coverage - Annual Maximums
Dental insurance Annual Maximums are another way that your employer and the dental insurance company limit their expenses and, of course, pass the cost on to you - the patient. The simplest way to think about it is - you have an account with a set amount in it each year. Most plans have an annual maximum of $1500. So, once the insurance company has paid a total of $1,500 towards all your treatment, they will stop paying. At this point, you will be responsible for the full amount. Some plans will allow you to continue to get the in-network discount.
While other plans let the dentist charge the full amount, in our office, we continue to offer our patients the insurance discount price even after they have reached their annual maximum. It's just like it sounds, in the beginning of the year, your $1,500 is replenished and you can start receiving benefits again. The only caveat with this is Ortho. Usually, Ortho or braces/invisalign come out of a separate account. Most plans will pay a lifetime amount of $1500 towards invisalign and braces. Once you have used this up, they will not pay any more.
Here are a few more “limitations” that are commonly used in dental insurance plans:
»Non-duplication of benefits – Some dental insurance plans won't pay for certain procedures if they are covered by another insurance plan. This may apply if you have dental insurance coverage under more than one plan (dual coverage).
»Pre-existing conditions – A pre-existing condition refers to an illness or other health condition that existed during the six months before you enrolled in your current dental insurance plan.
»Annual maximum – The annual maximum is the maximum dollar amount your dental insurance plan will cover for approved dental services during a calendar year.
»Deductible – The deductible is the amount of money you'll have to pay within the calendar year before your dental insurance coverage kicks in and starts to pay.
»Percent coinsurance – The percent coinsurance refers to the percentage of the costs (for covered dental services) you'll have to pay after you've met your deductible for the calendar year.
»Wait period – The amount of time you have to wait before your plan will start covering major treatment. Thus the insurance company gets their premiums prior to your getting the benefits.
»Pre-Authorization – The process to determine what your plan will and will not cover - by submitted clinical information and a request for review to your insurance company, they will mail you a letter describing your coverage. It’s the only way to know for sure what your plan will cover.
Dental Insurance Coverage - Need Some Help?
We know that dental insurance plans can leave your head spinning and full of questions. We have team members that work with plans like yours every day. And they are here to help. We can call to get your insurance breakdown once you have set up your first appointment.
We can also submit the paperwork to reauthorize your treatment. Finally, we will do our best to estimate any copays and deductibles for you prior to your appointment. Most of the time, we send patients home with an estimate prior to their appointment. This way they know what to expect. We really do try to minimize the billing surprise.
Have questions about your dental insurance plans? We can help. E-mail or call us: (650)-583-5880
We'd love to hear from you.
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Dr. Sherry Tsai works with most dental insurance plans in the Millbrae, San Bruno, Burlingame, San Mateo and the Bay Area
The Dental Select Copay Plan makes dental insurance easy and affordable. There are no annual maximums to track and all copayments are fixed. Plus, routine exams, cleanings, and fluoride treatments are 100% covered after a low deductible is met on all services.
No Annual Maximum
There’s no annual maximum on your coverage, so you can utilize whatever benefits you need, as often as you need.
Network Options
Texas and Utah residents can choose between our regional Gold and Platinum networks at enrollment.
Short Waiting Periods
Take advantage of your full benefits within one year of your coverage start date.
Fixed Copay
Dental on a budget? Copays are fixed so you’ll always know what you’re going to pay prior to your appointment
Discounts
Where available, discounts may be available on child and adult orthodontics, veneers, and teeth bleaching. Discount amounts may vary.
In-Network
Delta Dental Copays
Principal Dental Insurance Copay
Delta Dental Insurance Copay
FAQ
Available on our Gold or Platinum networks (Utah and Texas only).
How To Calculate Dental Copay
Currently, Dental Select offers plan effective dates are on the first day of each calendar month. You may choose your effective date during the plan selection process, where you also enter your zip code and number of dependents.
Dependents can include a spouse or domestic partner and each unmarried child, from birth to age 26, who is living with you in a regular parent-child relationship and for whom you can claim an exception on your federal taxes.
Yes. EyeMed Discount Vision is included with every dental plan. This is based on applicable laws, and reduced costs may vary by doctor location.
Discount Vision and Connection Hearing are also included. This is based on applicable laws, and reduced costs may vary by doctor location.
The Copay plan is only available in Texas and Utah. Click here to download a brochure.
Your deductible applies to all services and must be fully satisfied before plan benefits take effect.
Plan Highlights
- In-network preventive care is covered at 100%
- Fixed copays for procedures make budgeting easy
- No annual maximums
- No waiting periods
- Gold and Platinum network options
Legal
EXPENSES NOT COVERED: No benefits will be paid for expenses incurred:
In all states
- for services related to, performed in conjunction with, or resulting from a non-covered procedure.
- for charges in excess of the Contracted Fee Schedule or the Usual, Customary and Reasonable rate, whichever applies.
- for any treatment program which begins prior to the date the Insured is covered under the Policy.
- for crowns, inlays and onlays on teeth that can be restored by direct placement materials.
- for the replacement of crowns, bridges, inlays, onlays or prosthetic appliances within 5 years from the date of last placement.
- for any condition covered under any Workers’ Compensation Act or similar law.
- for services applied without cost by any municipality, county or other political subdivision or for which there would be no charge in the absence of insurance.
- for services that are applied toward the satisfaction of a Deductible, if any.
- for services subject to a Benefit Waiting Period.
- for charges resulting from changing from one provider to another while receiving treatment, or from receiving treatment from more than one provider for one dental procedure to the extent that the total charges billed exceed the amount incurred if one provider had performed all services.
- for Hospital facility charges for any dental procedure, including but not limited to: emergency room charges, surgical facility charges, Hospital confinement.
- for drugs or the dispensing of drugs.
- for oral hygiene instruction; plaque control; acid etch; prescription or take-home fluoride; broken appointments; completion of a claim form; OSHA/sterilization fees (Occupational Safety & Health Agency); or diagnostic photographs (except for orthodontic purposes).
- for implants (unless included in covered services); myofunctional therapy; athletic mouthguards; precision or semi-precision attachments; treatment of fractures, cysts, tumors, or lesions; maxillofacial prosthesis; orthognathic surgery; TMJ dysfunction; cleft palate; or anodontia.
- for orthodontia, unless included within the Benefit Schedule.
- for services to replace teeth that are missing (extracted or congenitally) prior to the Effective Date of the Policy. This limitation ends after 36 months of continuous coverage on the Policy. Abutment teeth will be reviewed for eligibility of prosthetic benefits.
- for composite, resin, or white fillings on posterior primary teeth. Benefits will be reduced to that of an amalgam or silver filling.
- for the replacement of a filling within 24 months of placement, unless for specific health reasons.
- for the replacement of retainers.
- for lab fees for higher metals or porcelain crowns, bridges, inlays, or onlays.
- during travel or activity outside the United States.
In Texas and Utah only
- for services and supplies not listed in the Benefit Schedule, not recognized as essential for the treatment of the condition according to accepted standards of practice or considered experimental, subject to the Right To Appeal provision contained in your Policy.
- for cosmetic procedures, including but not limited to veneers and bleaching of teeth and procedures performed primarily for cosmetic reasons, subject to the Right To Appeal provision contained in your Policy.
- for sealants not applied to permanent bicuspids or molars, applied at age 18 or older, applied 3 years from a previous sealant application, applied to a decayed tooth.
In all states, except Texas and Utah
- for services and supplies not listed in the Benefit Schedule, not recognized as essential for the treatment of the condition according to accepted standards of practice or considered experimental.
- for cosmetic procedures, including but not limited to veneers and bleaching of teeth and procedures performed primarily for cosmetic reasons.
- for sealants not applied to permanent bicuspids or molars, applied later than the end of the month in which a child reaches age 19, applied 3 years from a previous sealant application, applied to a decayed tooth.
This insurance does not apply to the extent that trade or economic sanctions or other laws or regulations prohibit Us from providing insurance, including, but not limited to, the payment of claims.
Dental Insurance Copay
This insurance does not apply to the extent that trade or economic sanctions or other laws or regulations prohibit Us from providing insurance, including, but not limited to, the payment of claims.