What's the difference between in-network and out-of-network dentists?

An in-network dentist has signed a contract with the insurance carrier agreeing to accept a discounted fee schedule. Because the practice has agreed to those negotiated rates, the patient's coinsurance is calculated against a lower number, which usually means lower out-of-pocket costs.

An out-of-network dentist has no contract with the carrier and is free to charge their usual fees. The carrier still pays a portion based on its own allowed amount — sometimes called the maximum allowable charge — but the patient is generally responsible for the gap between the carrier's allowed amount and the dentist's actual fee. This is known as balance billing.

Some PPO plans pay the same percentage in or out of network, but the allowed amounts are different, so the out-of-network patient still ends up paying more. DHMO plans usually require staying entirely within the network, with no out-of-network coverage at all.

Verification at the practice should always confirm network status for the specific plan, since carriers operate multiple plan networks and a dentist who is in-network for one Aetna plan may be out-of-network for another. Network status also drives whether a procedure is covered at the standard percentage or downgraded.

For patients, the takeaway is that in-network usually costs less, but a trusted out-of-network dentist can still be a reasonable choice — especially when the plan offers good out-of-network benefits and the dentist's fees are close to the allowed amount.