In‑Network vs. Out‑of‑Network With a dental insurance: Simple Number Examples
In‑Network vs. Out‑of‑Network: what is the difference
We will explain In‑Network vs. Out‑of‑Network with your dental insurance using simple number examples based on a typical Principal PPO dental plan. With a PPO, you can usually visit both in‑network and out‑of‑network dentists, but the costs are different. In‑network providers have a contract with Principal and agree to discounted fees, while out‑of‑network providers do not, which often leads to higher out‑of‑pocket costs.
Case 1: Preventive Visit In‑Network vs. Out‑of‑Network
Imagine your Principal PPO covers preventive care at 100 percent in‑network and 80 percent out‑of‑network.
Standard fee for a cleaning and exam: 150 dollars.
In‑network negotiated fee: 120 dollars.
Out‑of‑network dentist charges the full 150 dollars.
In‑network result:
Plan pays 100 percent of 120 dollars.
You pay 0 dollars (assuming no deductible on preventive care).
Out‑of‑network result (simplified example):
Plan covers 80 percent of an “allowed amount,” say 120 dollars.
Principal pays 96 dollars.
You pay 24 dollars coinsurance plus the 30‑dollar difference between the dentist’s 150‑dollar fee and the 120‑dollar allowed amount, for a total of 54 dollars out of pocket.
Case 2: Filling With Deductible and Coinsurance
Suppose:
Deductible: 50 dollars (not yet met).
In‑network PPO fee for a filling: 250 dollars.
Out‑of‑network dentist fee: 300 dollars.
Plan covers basic services at 80 percent after deductible.
In‑network:
You pay the first 50 dollars (deductible).
Remaining balance: 200 dollars.
Principal pays 80 percent = 160 dollars.
You pay 40 dollars more.
Total you pay: 90 dollars.
Out‑of‑network (simplified):
You pay your 50‑dollar deductible.
Plan’s allowed amount might be 250 dollars, even though the dentist charges 300 dollars.
Remaining allowed balance: 200 dollars; Principal pays 160 dollars (80 percent), you pay 40 dollars coinsurance.
You also pay the extra 50 dollars above the allowed amount (300 – 250).
Total you pay: 140 dollars.
This kind of example shows why Principal and other insurers emphasize that patients usually save more by staying in‑network.
Case 3: Hitting the Annual Maximum
Imagine your annual maximum is 1,500 dollars and you have already used 1,200 dollars this year. You now need a crown with an in‑network fee of 1,000 dollars, covered at 50 percent for major services.
Under normal conditions, Principal would pay 500 dollars (half of 1,000).
But you only have 300 dollars of annual maximum left (1,500 – 1,200).
Principal pays 300 dollars and you are responsible for the remaining 700 dollars.
This is why it can make sense to plan larger treatment in phases across two benefit years when possible.