What changes on your bill with in-network vs. out-of-network dental care?

You booked an appointment, got the care you needed, and then a bill showed up that didn't match what you expected. That gap often comes down to one thing: whether your dental provider is in-network or out-of-network. Going in-network typically means lower costs and less paperwork, but the exact difference depends on your dental plan. The main things to compare are the dental provider's fee, the amount your plan allows and who receives the insurance payment.  

What you’ll learn in this article: 

• In-network dental providers agree to a plan's set fees, which typically lowers your out-of-pocket costs. 

• Out-of-network care often costs more, as your plan may cover less or nothing at all. 

• Some dental offices will submit out-of-network claims on your behalf, though payment rules vary by plan. 

• A written estimate can help you budget, but it does not guarantee what your insurance will actually pay. 

If you're not sure whether your dental provider is in-network, schedule an appointment with an Aspen Dental provider to review your plan and get a clear cost estimate before treatment starts. 

What does "in-network" actually mean? 

An in-network dental provider has a contract with your dental plan. The dental provider agrees to the plan’s terms and fees for covered services. You may still owe your deductible, a set copay, part of the agreed fee or the cost of a service your plan does not cover. 

An out-of-network dental provider does not have that contract. Some plans still pay part of the bill, while others offer little or no out-of-network coverage. Check your plan and confirm the dental provider’s network status before treatment.

How does the cost actually differ? 

For covered in-network care, the plan and dental provider use an agreed fee. You may owe a deductible and part of that fee, but you generally do not pay the gap between the dental provider’s regular price and the plan’s contracted price. 

With out-of-network care, the dental provider’s full fee and the amount your plan allows may be different. The American Dental Association explains that your bill may include your deductible, your share of the allowed amount and any balance left between the plan’s payment and the dental provider’s full fee. Some plans do not pay for out-of-network care at all.¹ 

This is why out-of-network care may cost more even when your plan pays part of the bill. 

What is balance billing, and could it happen to you? 

Balance billing happens when you are charged the difference between the dental provider’s full fee and the amount covered by your plan. An out-of-network dental provider may bill you for that gap in addition to your deductible or normal share. For a covered in-network service, the dental provider generally accepts the plan’s contracted fee instead.¹ 

You may still owe the full price of a service your plan does not cover. Rules can also vary by plan and state, so ask for a written estimate before treatment. 

How does the claims process change? 

With in-network care, the dental office usually sends the claim to your insurer. You may pay an estimated share at the office, but the final amount can change after your plan processes the claim. 

Out-of-network care does not always mean you must file the claim yourself. The dental office may submit it, but some plans send the benefit payment to you instead of the dental provider. These payment rules can depend on your plan, state law and whether you assigned the benefit to the dental provider.² 

Before treatment, ask who will submit the claim, who will receive the insurance payment and how much you may need to pay upfront. 

How much will your plan actually pay? 

The amount your plan pays depends on its out-of-network rules. Your deductible, the percentage covered, the allowed amount, your yearly maximum and services the plan excludes can all affect the payment. Some plans pay less for out-of-network care, and some may not cover it. 

Ask your insurer these questions before you book: 

• Is this treatment covered out of network? 

• What amount does the plan allow for it? 

• What percentage of that amount will the plan pay? 

• Will my deductible or yearly maximum affect the payment? 

• Will the payment go to me or the dental office? 

These answers can help you decide whether an out-of-network visit is worth the cost for your situation. 

Why does any of this matter for your dental health? 

Cost and gaps in coverage can make dental care harder to get. The Centers for Disease Control and Prevention reports that among working-age adults, 43% of those without health insurance had untreated cavities, compared with 18% of those with private health insurance. It also notes that routine dental services are generally outside traditional Medicare coverage and that dental benefits for adults on Medicaid differ from one state to another.³ 

These figures are not a direct comparison of in-network and out-of-network dental care. Still, they show why it is important to understand your costs before they lead you to delay needed care. 

None of this means out-of-network care is off the table. Knowing the full cost ahead of time can help you avoid a surprise bill and choose the option that works for you. 

What if your dental provider leaves your insurance network mid-treatment? 

If your dental provider leaves the network during a longer treatment, the cost of your remaining visits may change. Do not assume your first estimate still applies. Call your insurer and the dental office to ask when the change takes effect and how completed and future services will be billed. 

It also helps to request a new written estimate. Learn more about what can happen to an unfinished treatment plan before your next visit. 

Do not let cost confusion get in the way of care you need. Ask about your coverage and get a written estimate before treatment starts. You can also contact your local dental office to ask about its network status and review your options. Confirm your coverage with your insurer. 

What changes on your bill with in-network vs. out-of-network dental care? FAQs 

Still have questions about in-network versus out-of-network dental care? These answers cover a few common questions. 

Who receives an out-of-network insurance payment? 

The payment may go to you or directly to the dental provider, depending on your plan and state law.² If it comes to you, you're responsible for paying your dental provider yourself, so let your dental office know as soon as you receive it to avoid a lapse in payment. 

How do I find out if a dental provider is in-network? 

Check your insurer’s online directory, then call the insurer to confirm. You can also ask the dental office, but your insurer has the final say on whether the dental provider is in-network for your specific plan. 

Does emergency dental care work the same way? 

Emergency benefits vary by plan. If you can, check your policy or call your insurer before treatment. If you have a serious or life-threatening emergency, get care first and handle the billing afterward. 

Will my plan tell me the exact amount I will owe before treatment? 

Ask your insurer whether it can provide a pretreatment estimate. If it does, treat the estimate as a guide rather than a guarantee of your final bill. 

Sources 

¹ American Dental Association, Practice, Dental Insurance: “How to read your Explanation of Benefits (EOB) Statement.” https://www.ada.org/resources/practice/dental-insurance/explanation-of-benefits-statement 

² American Dental Association, Practice, Dental Insurance: “Assignment of Benefits to Participating Dentists Only.” https://www.ada.org/resources/practice/dental-insurance/assignment-of-benefits-to-participating-dentists-only 

³ Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Oral Health: “Health Disparities in Oral Health.” https://www.cdc.gov/oral-health/health-equity/index.html