Lincoln Copays, Deductibles, and Coinsurance Definitions
Using your dental insurance plan might be easier to understand if you are familiar with frequently used health care terms and what they mean to you. It will also make it more tolerable to manage your costs when you learn how the costs impact your wallet. Here are the basic differences between copays, coinsurance, and out-of-pocket maximums.
Lincoln Insurance Network Access
Lincoln’s dental plans are most often PPO, Preferred Provider Organization. You certainly can see any dentist, but you will save the most money if you use a dentist in the Lincoln DentalConnect® PPO network because all fees are negotiated. Out-of-network care is covered, but you will pay more.
Preventive Care
Most dental plans cover preventive services at 100%, if in-network, with no deductible. This includes exams, professional teeth cleaning, and X-rays. Lincoln Insurance strongly emphasizes preventive care, so you will avoid higher costs at a later exam.
What is a Copay?
A copay, or copayment, is a fixed amount you pay for a covered health care service, usually at the time of the service. Here is how the copay works. You might remember when you went in for a dental visit and paid a $20 or $25 copay at the appointment. Copay amounts will vary depending on the provider and the treatment. With health plans that have copays, you will know exactly what you will pay ahead of time, which helps you budget your health care costs. For some plans, your copay does not apply toward your deductible. Some services might be covered at no additional charge, such as annual wellness exams and other preventive care services.
What is Coinsurance?
For basic and major services, such as fillings, crowns, or root canals, you usually first pay a deductible quite often of $25–$50 per person per year, waived for preventive. After the deductible, you then pay a percentage of the actual cost, coinsurance, and Lincoln pays the rest. Basic care, like fillings, extractions, etc., often is 80% insurance and 20% you. Major care, like crowns, bridges, dentures, etc., is often 50% insurance and 50% you. The exact percentages will vary by plan design.
What is an Out-of-Pocket Maximum or Limit
You might have heard terms like out-of-pocket maximum or limit. They are the same thing. Your out-of-pocket maximum or limit is the highest amount you will pay during an annual coverage period for your share of any costs. Most often, copays, deductibles, and coinsurance all add toward your out-of-pocket maximum. Your monthly premium, balance-billed charges, or anything not covered in your plan, like out-of-network costs, does not add to your maximum.
Each plan has a yearly benefit maximum, usually $1,000–$2,000 per person. Lincoln will pay claims up to that dollar limit; then you will be responsible for any additional costs.
How Does an Out-of-Pocket Maximum Work
If you reach your out-of-pocket maximum, your plan will then most often pay 100% of your covered health care costs, up to the allowed amount. Let us say you have an out-of-pocket maximum of $6,000. This means once you have paid $6,000 out of pocket in that year for your covered health care, most often including deductibles, copays, and coinsurance, your plan then covers any future, covered and in-network, health care services during your coverage period. If your provider charges you more than the plan's negotiated rate for a treatment, you might need to pay the difference, or a balance-billed charge.
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