In-Network vs. Out-of-Network: How Does Dental Insurance Work?

Dental insurance isn’t always the easiest topic to navigate. There are several different plans out there and they don’t work quite like your medical insurance does. It also pays to know the difference between seeing an in-network vs. out-of-network dentist so you can determine which provider is right for you. Continue reading to learn more about your options before your plan renews at the end of the calendar year.

What Types of Dental Insurance Plans Are Available?

There are two main types of insurance plans:

• Health Managed Organization (HMO): This plan offers dental care coverage for monthly or yearly fees. However, they provide coverage limited to providers that work in-network. This means that you will have a list of dentists in your area to choose from who have established a contract with the insurance company to provide dental care at pre-established rates. If you go to a dentist who is not on this list, it will not be covered by your plan.
• Preferred Provider Organization (PPO): PPO plans offer coverage to insurers at reduced rates too, but you are able to choose any provider you’d like, whether they are in or out-of-network. If you choose an in-network dentist, you will receive care at some pre-established rates, but if you choose an out-of-practice practitioner, a customary fee schedule will be established. You pay for the services you get and then file the claim to be reimbursed.

How Do In-Network Dentists Work?

When you see an in-network dentist for your dental needs, you will generally pay less at the time of service. In most cases, plans will cover 100% of preventive care, 80% of basic procedures, and 50% for more complex restorative procedures. You won’t have as much freedom when it comes to picking a dentist, but you will:

• Pay fewer out-of-pocket fees
• Receive higher coverage and benefits at the time of treatment
• Encounter lower prices on average

How Do Out-of-Network Dentists Work?

For PPO plans, your coverage from different treatments can range anywhere from 100% to 50% to 40% depending on your unique plan. These providers are not contracted with your insurance company, so they don’t have pre-established rates. A lot of the time, highly trained dentists work out-of-network, but you will usually end up spending more out-of-pocket since you have to pay at the time of your service. However, you can still file claims and have money reimbursed directly to you.

Now that the year is coming to a close soon, there is no better time to take advantage of your benefits. Starting on January 1^st, all unused benefits go to waste, and you will be responsible for paying your annual deductible again. Take care of your smile and your wallet!

About the Author

Dr. Ukti Phadnis earned her Doctor of Dental Medicine from the UConn School of Dental Medicine and has taken numerous continuing education courses to keep her knowledge and skills sharp. She has completed advanced training focused on dental implants, TMJ therapy, cosmetic dentistry, and Invisalign. Her practice accepts virtually all PPO dental insurance plans. To learn more about your benefits or to schedule an appointment at her office in West Hartford, visit her website or call (860) 236-4249.