Can my dentist charge me more than my dental plan allows?

Updated: Mar 18, 2023

Dental insurance plans are intended to help cover the cost of dental care for individuals and families. However, it's not uncommon for dental insurance plans to have limitations and restrictions on the amount of coverage they provide. This can leave patients wondering whether their dentist can charge them more than what their dental plan allows. The short answer is yes, but it's important to understand the details of how this works.

Dental insurance plans typically have a maximum annual benefit, which is the maximum amount of money the plan will pay out for covered services in a given year. If your dental procedure exceeds the maximum annual benefit of your insurance plan, you may be responsible for paying the remaining amount out-of-pocket.

In addition to the maximum annual benefit, dental insurance plans also typically have a list of covered procedures and a set fee schedule for each procedure. This fee schedule is the amount that the insurance company has negotiated with dental providers for each service. If your dentist charges more than the fee schedule for a particular procedure, you may be responsible for paying the difference.

This difference is known as "balance billing" Balance billing occurs when a dentist bills a patient for the difference between the dentist's fee and the amount covered by the insurance plan. Balance billing is legal in many states, but some states have laws that prohibit or limit it.

It's important to note that balance billing can be a significant expense for patients. Before undergoing any dental procedure, it's important to check with both your dental insurance plan and your dentist to determine what your out-of-pocket costs will be. If you're concerned about balance billing, you may want to consider looking for a dentist who is a participating provider in your insurance plan's network. Participating providers have agreed to accept the insurance plan's fee schedule and are less likely to balance bill patients.

It's also important to understand that dental insurance plans are not designed to cover all dental procedures or treatments. Some procedures may be excluded from coverage, or may be subject to limitations and waiting periods. In some cases, your dentist may recommend a procedure that is not covered by your insurance plan. In this case, you may be responsible for paying the full cost of the procedure out-of-pocket.

In conclusion, your dentist can charge you more than what your dental plan allows, and you may be responsible for paying the difference. It's important to understand your dental insurance plan's limitations and restrictions, as well as your dentist's fees and policies, before undergoing any dental procedure. By doing so, you can make informed decisions about your dental care and avoid unexpected out-of-pocket expenses.