Reviewed by Nicholas J. DiNinno III, DMD
Usually, yes — and the amount your plan pays is often closer to the in-network amount than people expect. The catch is that it depends entirely on which type of dental plan you have, and most people don’t know which one they’re holding.
Does dental insurance cover out-of-network dentists?
If you have a PPO plan — the most common type of dental insurance — yes. Your plan pays a percentage of covered treatment whether the dentist participates in its network or not. The out-of-network percentage is typically lower, and you may owe the difference between your dentist’s fee and what your plan considers allowable.
If you have a DHMO or DMO, no. These plans only pay for care from network dentists. If you have a discount or dental savings plan, that isn’t insurance at all — it’s a negotiated fee schedule at participating offices, and it does nothing outside them.
| Plan type | Out-of-network coverage |
|---|---|
| PPO | Yes, usually at a reduced percentage |
| Indemnity / traditional | Yes, often with no network distinction |
| DHMO / DMO | No |
| Discount / savings plan | No — participating offices only |
Find out which you have before anything else. It’s printed on your insurance card or in your benefits summary, and it determines everything that follows.
How does out-of-network reimbursement actually work?
Your plan defines an allowable amount for each procedure — sometimes called UCR (usual, customary and reasonable) or MAC (maximum allowable charge). It pays its percentage of that number, not of whatever the dentist charges.
So if your plan covers a crown at 50% out-of-network and considers $1,000 allowable, it pays $500. If your dentist’s fee is $1,200, you owe $700 rather than $600. The gap is real, but for most procedures it’s smaller than people assume.
The thing that removes most of the uncertainty is a written pre-treatment estimate submitted to your insurer, which tells you the actual number before you commit. How dental costs and insurance work at DiNinno Family Dental walks through the mechanism in more detail.
What should I ask my insurance company?
Call the member services number on your card and ask these four questions. Write down the answers.
- Is my plan a PPO, DHMO, or indemnity plan?
- What percentage does my plan pay out-of-network for preventive, basic, and major services? These are three different numbers.
- What is my annual maximum, and how much have I used this year?
- Do I have a deductible, and does it apply out-of-network?
Fifteen minutes on the phone will tell you more than any article can, because the answer is specific to your plan. If you have unused benefit left, it expires on December 31 and does not roll over.
Why don’t some dentists take my insurance?
Insurance networks set the fees a participating dentist may charge, and those fee schedules are often well below what the work costs to do a particular way. A practice that participates broadly generally has to make that math work somewhere — shorter appointments, cheaper laboratories, more patients per day.
Some practices decide they would rather set their own schedule than have an insurer set it. That isn’t automatically better dentistry, and you shouldn’t assume it is. But it’s the actual reason, and it’s worth understanding rather than reading network participation as a quality signal in either direction.
When should I just stay in-network?
Sometimes staying in-network is clearly the right decision, and anyone who tells you otherwise is selling something.
- You have a DHMO. Out-of-network isn’t covered. Full stop.
- Your budget is tight and the gap matters. A few hundred dollars is a few hundred dollars. In-network care from a good dentist is good dentistry.
- You’re happy with your current dentist. Continuity of care has real value. Don’t switch without a reason.
- You need extensive work and the difference compounds across many procedures.
Go out-of-network when there’s a specific reason: a dentist you trust, a complex case, a second opinion you want from someone particular, or a practice whose approach fits you better. “I want to” is a legitimate reason. “I didn’t know I could” isn’t. How to choose a dentist covers what to weigh once insurance is out of the way.
What if I don’t have dental insurance at all?
You have more options than the “pay full price” assumption suggests. Membership or in-house savings plans offered by many practices cover cleanings, exams, and X-rays at a reduced fee for a flat membership cost, with a discount on other treatment — no annual maximum, no waiting periods, no claims. For someone who mostly needs preventive care, the math often beats a low-end individual policy. How an in-office membership plan works explains who it suits and who it doesn’t.
Payment plans and third-party financing cover larger treatment. And sequencing matters: a dentist who plans treatment across two benefit years, or staggers work by urgency, can make a large plan manageable. Ask for this explicitly.
What should I ask a dental office before my first visit?
- Are you in-network with my plan? If not, what would my plan pay here?
- Can I get a written estimate before treatment starts?
- Do you offer a membership plan if I’m uninsured?
- What payment options do you have for larger treatment?
- If I need something extensive, will you show me the alternatives and what each costs?
An office that’s straightforward about money before you’re in the chair will generally be straightforward about it afterward.
Sources: American Dental Association — dental benefits and plan types. Massachusetts Division of Insurance — consumer information on dental plans.
General information about how dental benefits work, not advice about your specific plan. Confirm your own coverage with your insurer before treatment.
Related Reading
- Dental Costs and Insurance in Fitchburg, MA
- How to Choose a Dentist in Fitchburg, MA
- Dental Membership Plans in Fitchburg, MA
- Your Dental Benefits Expire December 31
Straightforward about cost, before you’re in the chair
DiNinno Family Dental has cared for families in Fitchburg since 1978. The practice is in-network with Blue Cross Blue Shield and fee-for-service otherwise — being out-of-network changes what your plan pays, not whether you can be seen. The office will help you work out your benefits and give you a written estimate before anything begins.
DiNinno Family Dental
931 South Street
Fitchburg, MA 01420
Office: (978) 342-8710
After hours (existing patients): (617) 302-6726
Request an appointment: dininnofamilydental.com/contact-us
Insurance and benefits: dininnofamilydental.com/patient-information/insurance
Monday 9:00 a.m. – 3:00 p.m. · Tuesday – Thursday 8:00 a.m. – 5:00 p.m. · Friday 8:00 a.m. – 1:00 p.m. Patients come to the South Street office from Fitchburg, Leominster, Westminster, Lunenburg, Ashby, Ashburnham, Townsend and Gardner.
Fitchburg Healthy Smiles is a patient education resource published by DiNinno Family Dental, 931 South Street, Fitchburg, MA 01420, (978) 342-8710. Information on this site is general in nature and is not a substitute for examination, diagnosis, or advice from a licensed dentist.
Leave a Reply