Anonymous asked in Business & FinanceInsurance · 1 decade ago

What usually falls under co-pay vs. co-insurance?

When does co-pay kick in vs. co-insurance? Generally speaking!!!

I've been reading up on health insurance and a lot of articles basically say "co-pay covers prescription drugs and doctor's visits".

Do they mean ROUTINE doctor's visits for things like a general physical, or a teeth cleaning?

I'm assuming co-pays cover small procedures like teeth cleanings, fillings, and physicals.

Co-insurance kicks in when you fall off a ladder or you make an appointment specifically for a root canal. Right?

Another QUICK related question!!!

Lets say I just bought dental insurance with a $1000 deductible. I have 10 cavities and a tooth that needs a $2000 procedure. It will cost me $1000 to fix my 10 cavities.

After I fix my cavities out of my own pocket, can I get the $2000 procedure done using my co-insurance rate? Or would they view it as a pre-existing condition?


4 Answers

  • 1 decade ago
    Favorite Answer

    Lots of questions.

    + HMO type plans tend to require a person to pay a co-pay which varies based on the type of medical treatment.A co-pay must be paid each time the provider is seen. Same with prescriptions - most today have three levels - generic, brand, and non preferred.

    + Traditional medical insurance plans usually cover treatment expenses following an annual up front deductible and then cost sharing e.g. 80% by the insurance company and 20% by the person. After the annual deductible has been met the cost sharing will continue up to an annual cost sharing maximum. After that coverage would be 100% up to the plans annual lifetime maximum.

    + Medical insurance generally does not cover dental expenses. The exception would an accident with damage to your teeth.

    + Routine MD office visits usually mean when a person is not feeling well or if the go for a preventive exam.

    + Dental insurance plans can be purchased. Most cover expenses on a cost sharing basis up to about $1,000 a year. A person may pay about $40 a month for single coverage.

    Source(s): Experience with medical and dental insurance
  • 1 decade ago

    Health insurance doesn't pay for teeth cleanings, or any dental stuff. That's different - it's DENTAL insurance.

    Copays are for doctor office visits and prescriptions. Coinsurance, is if you have to go into the hospital and stay there.

    And that dental, I've never seen a private policy to pay out more than it costs - that's because they have CAPS. The most MINE pays, regardless of what goes wrong, is $1000 a year.

    Most likely, you have a $1,000 deductible - which means you pay for 9 of those cavitites out of pocket. Then it probably pays 80% of the last cavity, and if you need a crown or root canal, it will pay usually HALF. Your coinsurance on that kinda stuff is 50%, and once the policy has paid out the annual limit - it's DONE.

    And, usually there are waiting periods - maybe a year, before you can get any major work done.

  • Nette
    Lv 5
    1 decade ago

    Generally speaking, a copay is a specified amount taken for an office visit or exam. A coinsurance is a percentage your are responsible for after your deductible has been met.

    All insurance plans are different so you need to read your benefits booklet to make sure you understand when each is taken.

    I doubt they would consider your $2000 procedure a pre-existing condition but you will need to check you limitations on your dental policy. They often only cover a certain amount per year.

  • 4 years ago

    No, you are responsible for all the maintenance of the house and grounds. THey don't replace broken windows, worn out roofs, they don't paint houses, all those things, AND the hazardous tree, are all considered maintenance. If your tree lands on the house, you'll have the homeowners deductible to pay. If it lands on someone else's house, and they can prove you knew it was hazardous, your insurance company can deny liability coverage for you. If you have another claim, and the adjuster comes out and notices the hazardous tree, they can require you to remove it within 30 days, or cancel your policy. Oh, and check your policy - if it lands on your house, usually there is a limit of $250 for "debris removal", which would be tree parts that land on your house. If it actually costs $2,000, you have to pay the rest. If you want a maintenance contract, it costs a WAY WAY lot more than an insurance policy - which is designed to cover UNEXPECTED losses.

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