Oral & Vision Health Blog

I thought this was covered. Why do I have a co-payment?

You've just bought insurance to cover dental and other health-related procedures, and what a great decision! Whether it was through work or wanting to obtain your own coverage, you learned about your benefits -- perhaps at your open enrollment meeting.

You were delighted to find that many procedures were covered by your plan! Whether it's something you might need but don't want such as a dental filling, or a service you want but don't necessarily need like cosmetic whitening.

Whether you're new to the insurance world or not, you know that your health benefits carry a lot of terms, acronyms and sometimes other complex details about what you're entitled to. Understanding the terms of your plan is very important.

Some people get confused when they have dental insurance but are still required to pay toward a procedure, even when it's covered under the policy. Each insurance plan has a predetermined (flat) fee that an individual pays for health care services, in addition to what the insurance covers. This is called a co-payment

Why do I have a co-payment?

A procedure is “covered” if your insurance company will pay for all or some of the cost. What is covered and to what extent is determined by your specific insurance benefit package. Certain procedures—often preventive services--might be covered completely at no charge to you.

If your insurer does not cover the complete cost of a procedure, you’ll need to come up with a co-payment (a flat fee) or co-insurance (a percentage of the full bill), depending on the type of dental plan you have. This is usually a small portion of the complete treatment cost.

Having a co-payment does not mean that the procedure is not covered. It simply means that your insurance company will pay most of the cost, and you are responsible for the rest.

Some types of dental plans have annual deductibles, which represent the out-of-pocket amount you must pay before your insurer will start to cover a higher portion of your total costs. Your deductible usually resets each year.

As a patient, it is important to educate yourself on what your plan covers and to what extent. Be sure to review your schedule of benefits, ask your employer or contact your insurance company’s member services department.

questions to ask the dentist