Dentists in many states can effectively ask you to pay the full un-discounted billed rate, rather than the negotiated rate, after you have reached your calendar-year maximum, even if the dentist is in-network.
Let’s say you’re used to paying to paying a 50% copay for a major dental service amounting to $400 from a negotiated rate of $800. The original billed rate may have been $1,000, but negotiations between your insurance company and your dentist resulted in your dentist accepting the $800 reimbursement as paid in full.
Let’s also say you have just reached your calendar-year maximum of $5,000, meaning that your dental insurance has paid out the maximum allowed in one year. But you still need the same procedure done as before. You may be expecting to pay out-of-pocket what the insurance company would have paid: $800. But because the insurance company is now out of the picture, your dentist is now allowed to charge you the full $1,000 un-discounted billed rate, even though you have dental insurance, they are in-network, and that the negotiated rate with your insurer for the same service was $800.
This arcane area of policy is termed non-covered services (NCS) and fee capping. Services may be not covered for a number of reasons: denial of medical necessity, limitations on number of services provided, etc. Anytime your dental work is not being paid by your dental insurance company, you may be asked to pay the full billed, un-discounted rate.
Unfortunately provisions from the recently enacted No Surprise Billing Act does not cover dentists. Your best bet is to directly ask your dentist the cost of your next visit if you have met your calendar-year maximum or are undergoing a procedure that is not covered by insurance.
