HMO vs. PPO Some Answered questions...maybe!

OK… it’s that time of year to figure out insurance for the coming year it’s narrowed to a dental HMO (DHMO) or dental PPO (DPPO) plan. And this is where it gets complicated and tedious! What’s the difference? Which is the best plan for you and your family right now?  You’ve asked around to friends’ family and whomever would listen, and they are not sure what you are talking about!

Here are 7 little tidbits for you:

Premium Cost

DHMO

Premiums on a DHMO plan typically are the least expensive of all the dental insurance plans, cover the minimum and are subject to odd restrictions…But you get what you pay for!

DPPO   

The premiums for a dental PPO plan tend to be more expensive than a DHMO plan.

Primary Care Dentist

DHMO   

Often, with a DHMO, you must select/or be assigned to a primary care dentist. 

Now, this is interesting…the dentist you pick is paid a monthly fee for you to see them even if they don’t do anything…

DPPO   

You are not assigned to a primary care dentist but have the freedom to go to any dentist you choose.

Provider Access  

DHMO   

You are only eligible for coverage if you visit an in-network provider for covered services.

DPPO   

With a DPPO plan, you receive coverage whether you visit an in-network or out-of-network dentist.

Payment

DHMO   

You pay the specific fee (copayment) listed on your Schedule of Benefits to the dentist for covered services. 

DPPO     

An in-network dentist has negotiated with the insurance company (with a steep discount to the members of that insurance plan) to charge up to a certain dollar amount for covered services. So, you pay a coinsurance (or patient’s portion or Co-Pay), which is a percentage of this negotiated fee and the insurance company pays the rest of the fee.

Claims

DHMO    

You don’t have to worry about filing claims. Your network dentist will file them for you.

DPPO    

Once you use a network provider, they will file your claims for you.

Deductibles

DHMO    

You pay no deductibles.

DPPO   

You do pay an annual deductible before using any benefits. This amount varies by insurance company and by plan.

Maximums       

DHMO    

You have no annual calendar maximums. However, there may be many exclusions (you had that filling done 2 or more years ago, and they will not cover it or you had that tooth pulled before you had that particular insurance so they will not pay to replace it.

DPPO   

You do have an annual calendar maximum. This amount varies by insurance company and by plan.