Coinsurance Explained [MetLife Dental PPO]

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Coinsurance is a method to split the cost of a procedure/service with your insurance. When it comes to SDPEBA's dental plans, only MetLife's PPO plan features a coinsurance model for Type A, B, C, and D services. 

Category of Care

In-Network Coinsurance

Out-of-Network Coinsurance

Type A - Preventative

100%

100%

Type B - Basic Restorative

90%

80%

Type C - Major Restorative

60%

50%

Type D - Orthodontia

50%

50%

As outlined on the MetLife PPO plan's summary of benefits, you the percentages listed in the chart above is the amount you are covered for. 

Meaning you pay the remaining portion for each of these services. For example, if you get in-network Type C care, you will pay 40% of your dental bill while MetLife pays the rest

Note, Type C and Type D care have a shared $50 annual deductible, click here for more information.  

What’s the difference between Coinsurance and Copay? 

Copay is a flat rate that is agreed upon between you and your insurance when you enroll for benefits. The rate is fixed, meaning no matter what, you’ll only pay the dollar amount listed on your explanation of benefits.  

Coinsurance, on the other hand, takes the cost of the procedure into account. An 80% coinsurance means you’ll pay 20% of whatever the costs of the procedure are. Meaning, if you that costs $1,000, you will only pay $200 and your insurance will cover the rest. 

Both coinsurance and copay are factored into your “annual maximum benefit" which is the total amount of money MetLife will pay out in a given benefit year. 

Other Notes 

Remember coinsurance for Type B and C services only kicks in AFTER your deductible is paid. Meaning, you’re responsible for the first $50 in dental expenses.  

Coinsurance can also represent the percent YOU pay rather than the percent your insurer pays, which is the case with the Sharp Saver plan. Pay close attention to your explanation of benefits so you know the amount you're covered for. 

Details and figures used in this article reflect the 2020-2021 Benefit Year.

 

For more on your MetLife Dental Plan, click here! 

Didn’t answer your question? Click here to head to our main support page. There you can search for more details or pose a question to our staff. You can also email us at info@sdpeba.org or call us at 888-315-8027! 

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