Reviewed by a licensed dentistTopic: Patient portionQuestion: How it's calculated
How is my share of the bill calculated?
The short answer
Your share comes down to four numbers: the plan's allowed amount for the service, your deductible, your coverage percentage, and how much of your annual maximum is left. Here's how they stack up.
More detail
The four pieces
- Allowed amount: the fee the plan sets for a service. In-network dentists have agreed to accept it for covered services.
- Deductible: what you pay before the plan starts paying. Cleanings and checkups often don't count toward it.
- Coverage percentage: the share the plan pays. Many plans pay more for preventive care and less for major work, such as 100% for cleanings, 80% for fillings, and 50% for crowns.
- Annual maximum: once the plan has paid this much in a year, it stops paying.
Example: a crown at an in-network dentist
These numbers are made up for illustration:
- Dentist's regular fee: $1,400
- Plan's allowed amount: $1,000
- Deductible: already met this year
- Plan pays 50% of $1,000: $500
- You pay: $500. You don't owe the $400 difference between the regular fee and the allowed amount.
Out of network
An out-of-network dentist hasn't agreed to the plan's fee. The plan pays its share of its own allowed amount, and you can be billed for the rest of the dentist's fee.
Questions to ask
- Are you in network with my plan?
- What's the allowed amount for this, and what's my estimated share?
- Does my deductible apply to this?