Why Do I Have Out-of-Pocket Costs If I Have PPO Dental Insurance?

Many patients are surprised when they get a bill at the dentist, even though they have insurance. It feels confusing — shouldn’t insurance cover everything? The truth is, dental insurance works differently than medical insurance, and understanding it can help you plan ahead.

1. Dental Insurance Covers Part, Not All

Dental insurance is designed to help with the cost, not completely cover every procedure.

• Preventive care like cleanings, exams, and X-rays may be fully covered.

  
  

• Restorative work (like fillings, crowns, or root canals) is usually only covered partially.

2. Each Plan Has Limits

Most dental plans have:

• Annual maximums (a set dollar amount insurance will pay each year, often $1,000–$2,000).Once those limits are reached, you pay the rest.

  
  

• Deductibles (the amount you pay before insurance starts helping). Once those limits are reached, you pay the rest. Insurance is entitled to charge the copay at any point. That is why your office might charge it on your first visit.

3. Coverage Varies by Procedure

Insurance companies usually group dental procedures into three categories:

• Preventive (typically covered 80–100%) – cleanings, exams, and some X-rays.

  
  

• Basic (usually 50–80%) – fillings and simple extractions.

  
  

• Major (anywhere from 0–50%) – crowns, bridges, and dentures.

  
  

👉 What this means is that you may still be responsible for part of the cost, depending on the type of treatment. These coverage percentages are not set by our office—they are determined by the insurance plan your employer or insurance agent selected.

4. Not All Services Are Covered

Even if you have a PPO plan, it doesn’t mean that every dental service is covered.

• Frequency: Insurance also sets rules about how often you can use certain benefits. This is called frequency.

• Guidelines: Every insurance has its own guidelines. They decide what is “necessary” and how much they will pay. Sometimes, they will only approve the most basic version of a treatment, even if your dentist recommends something better for your health. This is why you may see a difference between what the insurance pays and what your dentist recommends.

5. Insurance vs. Patient Responsibility

Think of dental insurance as a coupon that helps lower your bill, but it’s not a blank check. The dentist bills your insurance, they pay their part, and then you are responsible for the remaining balance.

“Having dental insurance can be a big help, but it’s important to understand how it works. Your insurance contract is between you and the insurance company, not the dental office. As a courtesy, we file claims on your behalf, but the insurance—not us—decides what to pay or deny.

When we give you a cost estimate, it’s only based on what your insurance tells us. It’s never a guarantee of payment, and the company can still reduce or deny benefits. Remember, we provide the treatment first and then have to wait for the insurance company to send their payment, which sometimes may not cover everything.

So, think of insurance as extra help toward your dental care, not full coverage. Our office will always work hard to help you maximize your benefits, but the final decision is always up to your insurance.”

✅ Takeaway: Having dental insurance makes care more affordable, but it won’t eliminate all costs. The best way to avoid surprises is to review your plan, ask your dental office for an estimate, and know what your coverage includes.

📞 Need help understanding your benefits? Call our office at 813-651-0165 and we’ll be happy to review your plan with you.