How to Understand Differences of Dental HMO and Dental PPO Plans

Forty-five million Americans don't have dental insurance, according to the Centers for Disease Control and Prevention, or CDC. If you have access to a dental plan, whether through an individual or group plan, it's important to understand the type of plan you have and how to utilize it without incurring any unexpected out-of-pocket costs. A health maintenance organization, or HMO, plan works a bit differently than a preferred provider organization, or PPO, plan.

Step 1

Review the differences between dental plan options. HMOs typically require you to use a network provider, while PPO plans provide some out-of-network coverage. This information may be outlined in brochures provided by the insurance company or on the dental insurance company's website. Note the premiums, co-pays, coinsurance and deductibles for each plan option. Typically, the HMO will have a lower premium than a PPO.

Step 2

Consider whether or not you're comfortable with having a primary care dentist that you're required to see before obtaining any specialized services. One of the defining characteristics of an HMO, whether dental or medical, is the requirement to choose a primary care provider, who serves as a "gatekeeper" for accessing other services. PPO plans allow you to see any dentist you'd like, though you may have to pay more out-of-pocket if you see a dentist outside of the network.

Step 3

Review each plan's co-pays and coinsurance. Dental HMO plans may not have any co-pays for preventative services like cleanings and exams, as long as you're seeing your primary care dentist. There may be a co-pay for other services like crowns and bridges; the co-pay is the same for each procedure regardless of which network dentist you see. For example, if a crown for a molar has a $50 co-pay, it will be $50 no matter which dentist you go to. PPO plans are based on coinsurance, which means the dental plan will pay a percentage of what the dentist charges for the procedure. For example, if a dentist charges $500 for a crown for a molar, and the coinsurance is 50 percent, your out-of-pocket cost is $250. If the dentist across the street charges $600 for the same procedure, your out-of-pocket cost is $300.

Step 4

Review each plan's deductible, if any, and benefit maximum, if any. Dental HMO plans may not have a deductible or maximum due to the cost controls in place through their network and primary care dentists. Dental PPO plans typically have a deductible and a maximum benefit amount. These vary from company to company, and may vary from plan to plan offered by the same company.

Tip

Dental discount plans are an alternative to HMO and PPO plans. They are less expensive than dental insurance, but provide less coverage.

Call each provider to see whether your dentist is listed in the HMO or PPO network. If your dentist is out-of-network, you may want to choose the PPO option so you can stay with the same dentist. If your dentist is in-network or you do not have a dentist, then you may be happier with an HMO dentist.

Warning

Orthodontia coverage isn't included in some dental plans. If this is an important benefit to you and your family, check to make sure this is a part of your plan.

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