Due to the Privacy Act and because your Dental Insurance Plan is a contract between the Insurance
Company and the Policy Holder, we, as a dental offices are limited to what information
we receive about your DENTAL COVERAGE. Before your dental visit, as all
Insurance Plans are different, be sure to understand YOURS. A copy of your
dental policy is always helpful to bring to our Dental Office.
If
you are not sure of something, our highly experienced team members would
gladly send an estimate on your behalf and go through your coverage to make it
easier to understand.
Here are some
pointers that can help you understand a little bit more about Insurance Coverage
as outlined by the Canadian Dental Association:
Waiving the Dental Plan - Co-Payment
Your dental plan
is a valuable benefit.
Many employers provide benefits, in addition to salaries, as a
method of paying their employees. In fact, the benefits portion usually ranges
from approximately 20 to 34 percent of the employee’s total compensation
package.
Independent research conducted by the Ontario Dental Association
indicates that, of the benefits provided to Canadian employees, dental coverage
consistently ranks as one of the most important and most desirable aspects of
employee benefit plans.
In order to be able to offer a dental plan, many employers are
developing creative alternatives in the design of benefit plans so that the
employee will share in the cost of the dental care. This fact sheet will
provide some information to help you understand how one of the most common
features – co-payment or co-insurance – works.
What plan
limitations are employers using to involve the employee in dental care costs?
Some of the most
common benefit plan designs currently being offered are:
(1) Annual
Deductible Amounts - In this case, the employee may be required to pay the
first $25 or $50 claimed every year.
(2) Frequency
limitations - Dental plans may limit the number of visits to the dentist each
year that will be covered by the insurance plan
(3) Annual Dollar Maximums Employers may create a maximum limit
(e.g., $1,500) that the dental plan will cover each year.
(4) Co-Payment (or co-insurance) Through a sharing formula
specified in the dental plan contract, the dental plan may only cover a
percentage of the eligible amount claimed. The employee is responsible for
paying the remainder.
When are
co-payments used?
Co-payments are
sometimes applied to diagnostic, preventative and basic services, but they are
more frequently applied to comprehensive or extensive services such as endodontics,
periodontics, prosthodontics and orthodontics. Sometimes your plan will cover
80 percent of the bill leaving you to pay the other 20 percent (an 80 – 20
co-pay), other times, it could be on a 50 – 50 basis, or even other amounts. It
all depends on the plan.
How do
co-payments work?
Here’s how it
works: Your dentist bills you for $100 for your dental treatment. Before the
claim form goes to your insurance company, you sign the claim form, verifying
that the charge is accurate and that you are financially responsible to the
dentist for the entire charge. This is an important step because your dental
plan may not cover the whole bill. For example, if your plan pays 80 percent of
an eligible expense of $100, your insurance company will cover the first $80
leaving you responsible for paying the remaining $20 as an out- of-pocket
expense.
Do I have to
pay the co-payment?
Yes. It is against
the law (insurance fraud) for you or your dentist to conspire to avoid paying
the co-payment. Not only is it a violation of the law, but it is contrary to
the regulations of the Royal College of Dental Surgeons of Ontario
By law, a claim made to an insurance company must be an accurate
description of services rendered and fees charged. This is why you are required
to sign the claim form before it is submitted to your insurance company.
How would an
insurance company know that I did not pay my share?
Insurance
companies reserve the right to request that the patient provide proof that the
co-payment has actually been paid. If the patient is unable to provide that
proof, the insurance company may demand that the patient make financial
restitution to the insurance company or it may apply the overpayment to future
claims payments.
What if my
dentist gives me a discount on certain fees?
Your dentist may
do this but this is very different from waiving a co-payment. If your dentist
discounts his/her fee to you by a certain percentage, then that discounted fee
must be the fee submitted to your insurance company as the whole fee charged
for the services rendered.
Your dental plan is a valuable benefit. Before you ask your
dentist to waive a co-payment, think about the consequences to you and your
dentist.
For more
information visit: http://www.oda.on.ca/
