What Patients Should Know About Out-of-Network Dental Insurance
Out-of-network dental insurance usually still pays something toward your care, but often not the percentage of your dentist's fee that you might expect. Many plans apply their coverage percentage to their own allowed amount, a price the insurer sets, rather than to the fee your dentist charges. You are responsible for the difference, along with any deductible and anything above your annual maximum. Knowing how your plan calculates benefits before treatment starts helps avoid surprises.
What is an allowed amount?
An allowed amount is the price your plan decides to recognize for a given procedure. Plans may call it a maximum allowable charge, a usual and customary fee or something similar. When a plan says it covers 80% of a filling, it may mean 80% of its own allowed amount. If the allowed amount is lower than your dentist's fee, the plan pays less than you might expect, and the remaining balance is yours.
Most dental plans also have an annual maximum, the most the plan will pay in a plan year. Once you reach it, the plan pays nothing more until the next plan year.
What is the Delta Dental lawsuit about?
In January 2026, ADA News reported on a proposed class-action lawsuit filed by patients against Delta Dental entities in federal court in New York. The suit alleges that Delta Dental told members their plans would cover a stated percentage of out-of-network care, but calculated payments from an internal price that it did not disclose, leaving patients with larger balances than they expected.
These are allegations. When this post was updated in October 2026, the case was still open and the court had not decided whether the claims have merit. You can read the ADA News report.
Whatever the outcome, the case highlights a question every patient can ask: how exactly does my plan calculate what it pays?
What does out-of-network mean at our office?
We are an out-of-network practice. We can help you understand how to use your benefits. You are responsible for amounts your plan does not pay.
Your insurance may still contribute to your care when you see an out-of-network dentist. What it contributes depends on your plan's rules, not on our fees. Many patients with complex or medically involved needs want treatment planned around their health first and their benefits second. You can read more about complex and medically involved care.
What should I ask my plan before treatment?
Does my plan cover out-of-network dentists, and at what percentage?
Is that percentage applied to the dentist's fee or to the plan's allowed amount?
Will the plan tell me its allowed amount for a specific procedure before treatment?
What is my deductible, my annual maximum and how much of it have I used?
Are there waiting periods, frequency limits or exclusions that apply to my treatment?
Write down the answers and the date of the call. Plans change, and so do allowed amounts.
Planning care with insurance in mind
The right treatment depends on your mouth and your health, not on your plan's rules. Insurance still matters to most families, though, and it is reasonable to plan timing around it when that is clinically safe. If your plan year ends soon, see whether unused dental benefits expire at the end of the year. If you are planning for retirement or a change in coverage, read about retirement and dental insurance. New patients start with a comprehensive dental exam. See our new-patient information, or call our Jacksonville office at 904-398-1549.
Sources
ADA News. Patient lawsuit alleges Delta Dental misrepresents out-of-network coverage. January 2026. Retrieved October 6, 2026.
Walsh v. Delta Dental Plans Association et al., No. 1:25-cv-10801 (S.D.N.Y., filed December 31, 2025). Docket summary via PacerMonitor. Retrieved October 6, 2026.
About the author. CJ Henley, DMD, is a general dentist in Jacksonville whose practice focuses on cosmetic and restorative dentistry, dental implants and dental care around head and neck cancer. Meet Dr. Henley.
CJ Henley, DMD, PA · 3675 Hendricks Avenue, Jacksonville, FL 32207 · 904-398-1549
Updated October 2026.