How your dental plan works (for employees)

This article is for employees who want to understand how their dental coverage works.

Note: If your benefits are managed by Gusto (including the broker integration), go to Benefits in your Gusto account to view your dental plan details.

Dental plans can be confusing because they sometimes show coverage for both in-network and out-of-network providers. The coverage works differently for each.

Understand in-network vs. out-of-network coverage

In-network dentists have agreed to a set rate with your insurance carrier. Your insurance pays the percentage of that rate shown on your Summary of Benefits and Coverage (SBC).

Out-of-network dentists have no agreement with your insurance carrier. Your insurance only pays a percentage of the “reasonable and customary” rate, which is the average price other dentists in your area charge for the same service. You pay the rest, including any amount above that rate.

In-network vs. out-of-network cost example

In this example, your plan covers preventative care at 100% and other procedures at 50%.

In-network: The negotiated rate for a procedure is $120. You pay $60 (50% of $120).
Out-of-network: The dentist charges $200, but the reasonable and customary rate is $120. You pay 50% of $120 ($60) plus the $80 difference, for a total of $140.

Staying in-network saves you money because the negotiated rate is usually lower than what out-of-network dentists charge.