What does out-of-network dental care mean?

Out-of-network dental care means your dentist does not have a contracted fee agreement with your insurance provider. Insurance may still contribute to treatment, but reimbursement is based on the insurer’s internal calculations rather than the dentist’s actual fee.

Does dental insurance always cover a percentage of the dentist’s fee?

Not necessarily. In many cases, insurance coverage percentages apply to an internal allowed amount, not the dentist’s actual fee, which can result in higher out-of-pocket costs for patients.

Why do some dental practices choose to be out of network?

Some practices remain out of network to prioritize treatment planning, material selection, and time spent based on patient needs rather than insurance limitations or fee schedules.

Is out-of-network dental care more expensive long term?

While initial costs may appear higher, thoughtfully planned dentistry can reduce repeated repairs, failures, and replacements, potentially lowering long-term biological and financial costs.

How can patients avoid surprises with dental insurance?

Patients should ask how benefits are calculated, request pre-treatment estimates, and discuss long-term treatment options openly with their dental provider before proceeding.

What Patients Should Know About Out-of-Network Dental Insurance

Jan 26

Written By C.J. Henley

Understand dental insurance and how it works at CJ Henley DMD Jacksonville

Transparency, Coverage Claims, and Why Thoughtful Dentistry Matters

Dental insurance is often marketed as simple: “We’ll cover 50–100% of your care.”
But recent developments suggest the reality may be far more complicated.

In January 2026, American Dental Association News reported on a class-action lawsuit alleging that Delta Dental misrepresented how out-of-network dental benefits are calculated.

According to the lawsuit, patients were led to believe that coverage percentages applied to a dentist’s actual fee—when in practice, reimbursement was based on a proprietary internal pricing system that was never clearly disclosed.

This matters—for patients and providers alike.

What the Lawsuit Alleges (In Plain English)

The lawsuit claims that:

• Patients were told their plan would cover a percentage of out-of-network care
• That percentage was not applied to the dentist’s actual fee
• Instead, reimbursement was calculated using an internal “allowed amount”
• The pricing methodology was not transparent to patients
• Patients were left with larger-than-expected balances

You can read the full ADA News report here:
🔗 https://adanews.ada.org/ada-news/2026/january/patient-lawsuit-alleges-delta-dental-misrepresents-out-of-network-coverage/

At the time of writing, the allegations remain unresolved, and Delta Dental has denied wrongdoing. But the case highlights a broader issue in dental insurance: confusion around coverage, reimbursement, and patient responsibility.

Why This Confusion Exists in Dentistry

Dental insurance was never designed to function like medical insurance.

Most dental plans:
• Cap annual benefits (often $1,000–$2,000)
• Use internal fee schedules
• Do not adjust benefits meaningfully for complexity or longevity
• Have not kept pace with modern materials or techniques

As a result, insurance often prioritizes cost containment, not clinical outcomes. Learn more about dental insurance plans and costs here

This is one reason many practices—especially those focused on complex, restorative, or long-term care—choose to remain out of network.

Learn more about dental insurance costs here: 🔗https://www.cjhenleydmd.com/retirement-and-dental-insurance

What “Out-of-Network” Actually Means

Being out of network does not mean your insurance doesn’t work.

It means:
• Your dentist sets fees based on care, time, materials, and expertise
• Insurance reimburses according to its internal rules
• Patients maintain freedom to choose their provider
• Treatment planning is not dictated by insurance limitations

At CJ Henley, DMD, PA, our focus is on thoughtful treatment planning, not insurance-driven decisions.

We believe patients deserve:
• Clear explanations of costs
• Honest expectations about coverage
• Dentistry designed for durability—not shortcuts

You can learn more about our approach to long-term, medically involved, and complex care here:
🔗 https://www.cjhenleydmd.com/complex-medically-involved-care

Why This Matters for Long-Term Dental Health

Insurance limitations can unintentionally encourage:
• Delayed care
• Patchwork treatment
• Short-term fixes
• Repeated replacement of failing work

Over time, this can cost patients more—financially and biologically.

For many patients, investing in durable, well-planned dentistry aligns more closely with long-term health goals—especially for those thinking ahead to retirement, fixed incomes, or medically complex futures.

If you’re planning long-term dental care alongside retirement or insurance transitions, this page may be helpful:
🔗 https://www.cjhenleydmd.com/new-patients

Our Philosophy: Transparency First

We don’t believe dentistry should feel adversarial—between patients, providers, and insurance companies.

Our commitment is to:
• Explain treatment options clearly
• Help patients understand insurance realities
• Support informed decision-making
• Advocate for care that lasts

Whether you are in network, out of network, insured, or uninsured, the goal remains the same:

Dentistry that is biologically sound, thoughtfully planned, and built to last.

Final Thoughts

The ADA News lawsuit doesn’t just raise legal questions—it raises awareness.

Patients deserve transparency.
Dentists deserve autonomy.
Care decisions should be driven by health, not hidden formulas.

If you have questions about insurance, coverage, or how to plan dental care with clarity and confidence, we’re always happy to have that conversation.

Last reviewed and updated: January 2026

C.J. Henley https://www.henleyandkelly.com