Co-payment—also called co-insurance—is the portion of the bill that is your own responsibility. It’s the most common way for dental plans to limit their costs, thereby providing various plans with an assortment of benefits and price points for the purchaser to choose.Some plans are also taking other approaches to limit plan spending: setting annual deductibles, capping the dollar amount or limiting the number of visits covered within a year.

How much do I have to pay?

That depends on your plan.An 80/20 co-payment is common for basic procedures such as x-rays, cleaning, fillings and root canals. This means that the dental plan covers 80% of the bill. A 50/50 co-payment is common for major procedures such as crowns and bridges.But there are many variations; be sure to check your specific plan.

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 (RCDSO) that regulates the dental profession. This practice is considered professional misconduct and a dentist can lose his license for it, as well as incurring hefty fines, often exceeding $10,000. 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.

At DentalX Downsview Clinic, we’re always here to help.

For more information please visit https://www.cda-adc.ca/en/oral_health/talk/copayment.asp