141 Dental Studio

In-Network vs. Out-Of-Network

A lot of you with PPO benefits may have seen something that shows a difference between in-netowrk and out-of-network. It means exactly what it sounds like. Like stated in a previous post, with a PPO plan you generally have the freedom to go to any dentist or specialist you wish.

In-Network

If your dentist is in the dental insurance network then that means that have agreed to see patients insured by that particular insurance company at a discounted fee. The insurance company will reimburse the dentist at their UCR (usual, customary and reasonable) rate. This rate, because it is discounted, is less than what the dentist normally charges for a particular service and is determined by the insurance company. The dentist cannot charge the difference between what the insurance reimburses and their normal office fee. Usually, in-network is reimbursed as follows:

Preventive (cleanings, x-rays, exams): 100%
Basic (fillings, certain types of x-rays): 80%
Major (crowns, dentures, bridges): 50%
Orthodontics (braces): 50%

Out-of-Network

If they are out-of-network, then the dentist does not have an agreement with your insurance company. The insurance company will reimburse the dentist their portion and you (the patient) are responsible for the difference. Out-of-network is usually reimbursed as follows:

Preventive: 80%
Basic: 60%
Major: 50%
Orthodontics: 50%

Some people may ask, “Well, if the PPO plan pays more then why would I go to somebody not in my network?” There are several reasons:

    1. Your dentist may be family, a close friend or colleague that you trust and want to support.
    2. This is a dentist you’ve always gone to and they are not or no longer on the panel.
    3. This may be a specialist that is not on the panel.
    4. This may be the only dentist in your area.
    5. You may be out of town and need emergency dental service and the dentist is not on the panel.

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Another word of caution: YOU must know what your plan covers as plans differ greatly and some PPO plans may not have out-of-network benefits. This is not very common, but is a possibility so read and understand your plan carefully. Also, orthodontic treatment may only be covered for persons 21 years of age and younger. Additionally, you may have a deductible that needs to be met (usually $50-100) and a yearly maximum in the amount the plan will cover (usually $1000-2000). The reimbursement rates, deductibles and maximums I listed above are only examples of what I have seen. Your plan may differ.

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30 E 60th St., Suite 1101, New York, NY 10022 212.262.2952