Navigating the world of dental insurance can be challenging. With the vast number of acronyms and confusing descriptions, it’s hard to understand what exactly you’re paying for and how it can benefit. Many times, patients are surprised with how little their insurance covers and are left wondering what their monthly payments or deductions are going towards. At 32ology Dental Studio, cosmetic dentist Argina Kudaverdian, DDS and her professional team are here to help you understand the basics of dental insurance by explaining the two main types: PPO and HMO.
What is PPO Dental Insurance?
PPO stands for Preferred Provider Organization, which is a type of dental coverage that operates within a network of dentists who have agreed to provide services to plan members at discounted rates. These dentists who have agreed to discounted rates are referred to as “in-network” providers. So, for example, your dentist’s usual and customary fee (UCR) fee for a dental cleaning may be $130. But if he or she is in network with your PPO insurance, the contracted fee could be set to $100. The actual amount that the patient will have to pay, or co-pay, will depend on what percentage of that treatment insurance is willing to cover. So, in this example, even though the fee is $100, the plan coverage could be 75% for cleanings, so your co-pay will be $75. Each insurance company has various plans with differing coverages, with the most expensive plans being the ones that cover higher percentages of procedures.
What is HMO Dental Insurance?
HMO stands for Health Maintenance Organization, which means you are assigned to a specific dentist that is contracted with your HMO plan. You cannot choose the provider that you prefer or like. Also, if you need to see a specialist or have an emergency, you may only go to your assigned dentist.
Differences Between PPO and HMO
Let’s look into the major difference between these two insurance types.
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Network of Providers
- PPO plans generally have a larger network of dentists which you can choose from. You have the flexibility to visit any dentist, but you may pay slightly less if your provider is in network. Referrals are not required if you choose to see a specialist at any time. Your services will still have coverage whether you visit a dentist in network or out of network.
- HMO plans have a more restricted network of providers. You are assigned to a primary dentist in the network and all the care goes through this dentist first. Referrals are usually required to see specialists. So, if you are having an emergency and your assigned dentist is unavailable or far from you, you will not be able to use your insurance if you choose to go to another dentist.
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Cost
- PPO plans generally have higher monthly payments compared to HMO plans. However, they have lower out-of-pocket costs at the visits, even if you choose to see a dentist outside the network. The difference between co-pay amounts for “in-network” and “out-of-network” is only about 10%.
- HMO plans typically have the lowest monthly payments but cover only the bare minimum of services. Patients typically need to pay additional fees for upgraded materials or to get higher quality dental crowns/fillings that are otherwise included with PPO coverages.
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Deductibles and Maximums
- PPO insurances require patients to pay an annual deductible or a certain dollar amount before their insurance starts covering any services. The amount varies between different companies and plans. They also have a yearly limit to the dollar amount that can be used for dental services rendered which is called the maximum. So, if the treatment costs in a calendar year exceed the maximum, the insurance will no longer cover the remaining portion that exceeds the maximum and you will be responsible for it.
- HMO plans do not have any deductibles, nor do they have yearly or calendar maximums, but there is a dollar amount you must pay first before your insurance starts covering your treatment. You are only responsible for the co-payments at the time of services rendered.
Please make sure to read any exclusions or limitations to maximums that may exist in your policy.
As you can see, taking advantage of your insurance requires a thorough understanding of the limitations and responsibilities. It can be really confusing when assessing if dental insurance is worth it based on your dental needs. We understand that not every patient will choose or maintain dental insurance, and our office believes that this should never prevent you from receiving the services you need. At 32ology, we have created an in-house insurance policy that covers all your dental needs. If you have any questions regarding this membership, contact our office today.