When it comes to dental care, many people rely on their insurance coverage to help manage costs.
Dental insurance can be a valuable resource to afford dental care, but dental insurance benefits have not not changed since they started. You get anywhere from $1000- 2500 per year so to truly maximize the benefits, it’s crucial to understand how your plan works.
The majority of people who have dental and health care insurance obtain it through their employers during open enrollment, only a small minority understands the complexities of insurance well enough to feel like they made an empowered choice.
Understanding the key differences between PPO and HMO plans and how to make the right choice for you can be overwhelming.
There may be situations where you find yourself in need of dental treatment but without your insurance card or you don’t know who your coverage is under.
Many patients think their medical insurance and dental insurance are one in the same. That is not always the case.
Know who your dental coverage is under.
The fastest way to get that information is to contact your human resource department at your workplace. If your coverage is through the marketplace there should be a website or phone number to call for information.
Understanding Your Plan
- Types of Plans: Dental insurance plans commonly come in three types: Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), and Indemnity plans (HDHP).
- Make sure you understand the differences and limitations of each.
- Covered Procedures: Dental plans often follow a “100-80-50” coverage structure, covering 100% of preventive care (like cleanings, exams and x rays), 80% of basic procedures (like fillings), and 50% of major procedures (like crowns or root canals).
- Annual Maximum: Most plans have an annual maximum benefit limit of $1000-2500 per year. Knowing this number will help you plan for any significant dental work you may need so you can do part this year and part next year reducing your out of pocket expenses.
- Preferred Providers: Using a dentist in your plan’s network can save you money. Check if your current dentist is a preferred provider or consider switching to one that is. We will discuss this more in a moment.
- Waiting Period: Some plans have waiting periods for certain procedures, meaning you must be enrolled in the plan for a specific amount of time before you are eligible for reduced rates on certain services.
- Exclusions: Be aware of services that are not covered at all. You will be responsible for 100% of the cost for these procedures.
- Pre-authorization: Some plans require pre-authorization for certain procedures. Make sure to ask questions beforehand to avoid surprises.
Understanding the difference between Dental Health Maintenance Organization (DHMO or HMO) and Dental Preferred Provider Organization (DPPO or PPO) plans is important when choosing the right dental insurance for you or your family. Both types of plans come with their own set of pros and cons. Here’s how they differ:
HMO vs. PPO: Which Is Right for You?
The main differences between an HMO and a PPO come down to:
- Cost
- Size of plan network
- Access to doctors and specialists
- Coverage, out-of-network services and out of pocket expenses
If you’re in good health with no special medical needs on the horizon, check out an HMO. If you have ongoing health care needs or just want to have greater flexibility when it comes to your providers, a PPO could be the right choice.
Figuring out what type of health care plan is best for you can get confusing, so don’t go it alone! There are experts available to help you pick the best plan for you and your family. They’ll guide you through the process of choosing coverage so you can save money and stay on target to hit your money and health goals faster.
If you need to make a choice to help you decide, here is a simple comparison that lays out the basic features of HMOs and PPOs. Once you have a better understanding of each plan type and how they work, it will be much easier to choose the plan that’s best for you and your family during open enrollment.
Generally speaking, an HMO might make sense if lower costs are most important and if you don’t mind using a PCP to manage your care. A PPO may be better if you already have a doctor or medical team that you want to keep but doesn’t belong to your plan network.
What Are the Key Differences Between an HMO vs. PPO ?
The main differences between HMOs and PPOs are affordability and flexibility.
- HMOs have lower premiums and out-of-pocket expenses but less flexibility.
The biggest draw to HMOs are the lower premiums and out-of-pocket expenses. The premium—is the amount you pay each month for health insurance—it is lower in part because you have a smaller pool of providers to choose from, which means less flexibility in where you can go for care. An HMO requires that you get a referral to an in-network specialist from your primary care physician PCP. An HMO, is a plan that offers members care within a specific network of doctors, hospitals, and other medical providers. These are called in-network providers.
Your costs are typically lower with an HMO because it already has agreements in place with providers. They pay less to providers they have contracts with, so you pay less for the plan.
If you use a provider that isn’t in the HMO’s network, known as an out-of-network provider, the plan typically won’t cover your visit unless it’s an emergency.
As an HMO member, you pay a monthly premium and a copay when you seek care. You choose a primary care doctor to coordinate your care. If you need to see a specialist, your primary care doctor must give you a referral.
Translation: Your HMO keeps tabs on what they think is a medically necessary service, which helps them monitor and maintain overall plan costs. They determine what they will pay for regarding your care.
- HMOs have a low or no annual deductible.
Another key selling point to an HMO is its low or no annual deductible. That means the amount you have to pay before coverage kicks in could be as little as zero bucks.
- Count on a copay with an HMO.
If you enroll in an HMO, expect a copay—this is the set amount you pay for a covered medical service—on every non-preventive medical visit. For example.. Need to go in for your annual physical? No copay necessary.
Got the flu and need to see the doctor? You’ll pay a copay. And don’t forget, if you see a doctor outside of your network, get ready to pay up to 100% of the cost. Always prepare to see an in-network provider and know that you won’t have a ton of wiggle room if you need to see a specialist. An appointment with a specialist will require a referral from your PCP.
- PPOs have higher premiums but more flexibility.
While you can expect a higher monthly premium with a PPO, you can also count on a greater selection of providers and the freedom to see a specialist without a referral from your PCP. If you see specialists frequently or want to have fewer restrictions on out-of-network providers, this is the plan for you.
With a PPO, or preferred provider organization, there’s more flexibility where you seek care. You can see doctors who are out-of-network. You can also see a specialist without getting a referral.
But if you get care from a provider that’s in the PPO network, you pay less. Your out-of-pocket costs will be lower and your coverage will be more thorough.
If you choose care from a provider that’s out-of-network, your out-of-pocket costs will be higher. You’ll pay more for some services, and others may not be covered at all.
Your PPO has agreements with in-network providers to pay a set fee for each service. PPOs usually have a set rate they will pay for an out-of-network service or provider. If you go out-of-network and the doctor or medical facility charges more for a service, you have to pay the difference.
- PPOs typically have a higher deductible but there’s a reason why.
With a PPO, the deductible (like the monthly premium) is typically higher than an HMO. Why? Well, you’re paying for access to a greater network of providers and more flexibility with who you can see and where you can see them.
- Do PPOs have copays? Maybe yes. Maybe not.
It depends..Is everyone’s favorite answer— There are non-copay PPO plans and copay PPO plans. Check with your employer or health insurance provider to see which one you’ve got.
- There are also HMOs and PPOs that could be HDHPs.
While PPOs have historically been employers’ go-to health insurance plans, high deductible health plans (HDHP) have been picking up steam in recent years as a way to lower health costs for employees. In 2020, a plan qualifies as an HDHP if it has a minimum annual deductible of $1,400 for single coverage or $2,800 for family coverage.
If you’re healthy and don’t require much medical attention, an HDHP could mean a lower monthly premium than a PPO. While it’s possible for an HMO to also be an HDHP, it’s less likely since one of the key perks of an HMO is a low or no annual deductible.
If you have an HDHP, then you get the added bonus of enrolling in a Health Saving Account(HSA) where you can add and take out money tax-free to use for a huge range of qualified medical expenses.
Medicare HMO and PPO
Medicare also has both PPO and HMO options. If you are eligible or over the age of 65, you might want to check out
Making your decision
Now that you understand the major differences between the 3 types of insurance, you may have an idea of which 1 makes the most sense in your situation.
But if you’re still undecided about individual medical plans and would like even more information to make your decision.
Cost.
Pricing Structures Differ
HMO pricing is set (you pay only your co-pay for covered services), but there are a few restrictions; you must see a provider who is in your network, and you must select a primary care provider (PCP). PPOs offer greater freedom in that you can see providers out of network, but pricing can fluctuate dramatically depending on a variety of variables, including who you see, whether the visit applies to your deductible, and whether the provider you see is in network.
HMOs are more budget-friendly than PPOs. HMOs usually have lower monthly premiums. Both may require you to meet a deductible before services are covered, but it’s less common with an HMO. With a PPO, your monthly premiums may be higher, but you will have some coverage if you go out-of-network. HMOs typically don’t provide coverage for out-of-network providers unless it’s an emergency
Medicare is basic health insurance provided by the Federal government for people 65 and older, and people under 65 who meet certain criteria. When you sign up for Medicare, you are signing up for Part A and Part B. This is the first step to completing your Medicare coverage.
Medicare consists of 4 separate parts:
- Part A (Part of Original Medicare offered by the Federal government)
- Part B (Part of Original Medicare offered by the Federal government)
- Part C (Medicare Advantage plans offered by private insurance companies)
- Part D (Drug coverage offered by private insurance companies)
Why do you need additional coverage?
Many people discover that relying on Original Medicare (Part A and Part B) doesn’t provide enough coverage. With Original Medicare, there are gaps in your coverage. For example, Original Medicare only covers 80% of Part B expenses after the annual Part B deductible is met. The remaining 20% is your responsibility and could add up to thousands of dollars each year. Plus, Original Medicare doesn’t include Part D prescription drug coverage, routine vision and hearing exams, and certain other services.
Preferred Providers and Locations
If you have a preferred PCP and/or location, know that you might need to switch if you choose an HMO plan. HMOs require that you designate one PCP with your insurance who is responsible for managing and coordinating your health care. An HMO plan may limit your ability to see doctors you’ve seen in the past if they’re not in network.
PPO plans offer greater flexibility in this regard because you can book appointments with providers who are in the PPO network as well as providers who are out of network (although you may pay a higher rate if you choose the latter).
Seeing Specialists
If you have an HMO plan, you’ll need a referral from your PCP if you need to see a specialist, even for routine services such as seeing a dermatologist to get a mole checked out. PPO plans often don’t require referrals which mean that you can book appointments with specialists directly without conferring with your PCP.
While the freedom of a PPO plan may sound appealing, keep in mind that PCPs play a valuable role in helping you evaluate the best plan of action for your health goals. In addition to evaluating treatment options, your PCP can help you avoid expensive and unnecessary tests and procedures that a specialist might otherwise order for you. So regardless of whether you choose a PPO or HMO, we recommend you get in the habit of consulting with your PCP prior to making any medical decision.
How to Tell if Your Dentist is In-Network
Are you looking for a new dentist, or not sure if your current dentist is in-network? Here’s how to find an in network dentist:
- Go to your company’s human resource director, contact your insurance provider or ask the dental office.
- Find your plan type by logging into your account. If you don’t have an account, you can register for one depending on the company.
- Click on “Provider Search” to look up your dentist or find an in-network dentist in your area. You can search by address, zip code or dentist’s name.
- Our “Provider Search” will show you what networks the dentist participates in.
You will likely save the most and maximize your benefit dollars by choosing a PPO dentist. PPO dentists agree to PPO fees, which are greatly reduced from what a dentist would typically charge, as payment in full. You will pay more out-of-pocket with an out-of-network dentist compared to an in-network-dentist.
In-network dentists agree not to “balance bill” patients, meaning they won’t charge patients the difference between the pre-established fee and their usual fee.
You can also have a conversation with your dentist office about network status. Not all dentists accept insurance companies negotiated fees so be sure to confirm which networks they participate in before making an appointment..
Can I Go to the Dentist Without My Insurance Card?
The answer is yes, you can. Dental offices understand that patients may sometimes forget or misplace their insurance cards. In such situations, there are a few options available to ensure you still receive the dental care you need.
Provide Your Insurance Information
Although you may not have your physical insurance card with you, you can still provide your insurance information if you know it. Most dental offices have a system in place where they can verify your coverage by entering your details into their database. Be prepared to provide the following information:
- Insurance company name
- Policyholder’s name and date of birth
- Policy or group number
- Employer name
By supplying this information, the dental office can contact your insurance provider to confirm your coverage and process your claim accordingly.
Call Your Insurance Provider
If you don’t have your insurance card on hand and are unsure about the details, you can call your insurance provider directly. The customer service representative will assist you in retrieving the necessary information and guide you on the steps to take. Once you have the required details, you can inform the dental office to ensure a smooth process.
Pay Out of Pocket and Seek Reimbursement from insurance
If you’re unable to provide your insurance information or if the dental office doesn’t accept your insurance, you have the option to pay for the treatment out of pocket or pay with FSA or HSA. This can be an immediate solution to address your dental needs without delay.
Summary:
- HMO: Lower cost, limited network, less flexibility, and fewer out-of-pocket expenses but potentially longer wait times for specialized services.
- PPO: Higher cost, broader network, more flexibility, and quicker access to specialists but potentially higher out-of-pocket costs and annual maximum limits.
Dental HMO (DHMO)
- Network Restrictions: HMO plans require you to choose a primary care dentist (PCD) from a specific network of providers. You must visit this dentist for all dental work, and if you need to see a specialist, you’ll need a referral from your PCD.
- Low Cost: HMO plans often come with lower premiums and minimal or no deductibles.
- Co-payments: You pay a fixed amount (co-payment) for each service, which is usually quite low, but there is often no coverage if you go outside the network.
- Speed of Service: Because all services funnel through your PCD, getting appointments for specialized treatments could take longer due to the need for a referral.
- Predictable Costs: Costs are often more predictable and easier to understand because you pay fixed co-payments for procedures.
- No Annual Maximum: Most HMO plans don’t have an annual maximum limit on coverage, but there may be limitations on the number of certain types of visits or procedures.
- Less Paperwork: You don’t have to submit reimbursement claims when you stick to network dentists.
Dental PPO (DPPO)
- Network Flexibility: PPO plans provide more flexibility in choosing a dentist and don’t require you to pick a primary care dentist. You can visit any dentist or specialist without a referral, but you’ll pay less if you choose a dentist within the PPO network.
- Higher Cost: PPO plans usually have higher monthly premiums and often have a deductible you need to meet before insurance starts to cover costs.
- Percentage-Based Coverage: Unlike fixed co-payments in HMOs, PPOs often cover a percentage of the dental service cost (often based on a 100-80-50 structure for preventive, basic, and major services, respectively).
- Annual Maximum: PPO plans often come with an annual maximum limit on coverage.
- Out-of-Network Options: You can visit out-of-network providers, although you’ll typically pay more out-of-pocket. You may also need to file claims for reimbursement.
- More Immediate Access to Specialists: No referral is needed to see a specialist, offering quicker access to specialized treatments.
- Potential for More Paperwork: Depending on the plan, you may need to pay upfront and file a claim to get reimbursed for out-of-network visits.
Understanding these key differences can help you make a more informed decision about which dental insurance plan will best meet your needs.
Financial Planning
- Flexible Spending Account (FSA) or Health Savings Account (HSA): If you have an FSA or HSA, you can use pre-tax dollars for dental expenses, which effectively gives you a discount.
- Payment Plans: If a procedure is not fully covered, ask your dentist about payment plans or discounts for paying upfront.
- Alternative Treatments: Discuss less expensive treatment options with your dentist. Sometimes there are more cost-effective treatments that are equally effective.
Plan Your Visits
- Regular Check-ups: Take full advantage of your plan’s coverage for preventive care. Regular check-ups can catch problems early, saving you money in the long run.
- Timing: Consider the timing of more expensive procedures, so you don’t exceed your annual maximum. If you are near the end of the calendar year, you may be able to split the treatment between two years to maximize benefits.
- Multiple Appointments: For families, aim to schedule multiple appointments on the same day to save on travel time and potentially receive multiple-visit discounts.
Communication
- Discuss with Your Dentist: Be upfront about your insurance limitations and financial concerns. Your dentist may be able to help you strategize the most cost-effective way to handle your dental care.
- Insurance Company: Keep the lines of communication open with your insurance provider. If you have any questions or concerns, it’s often better to clarify directly with them.
Understanding your dental insurance can be complicated, but taking the time to understand its intricacies can lead to significant financial savings and better dental care.
Keep in mind Insurance is a business just like health care they are not in the business of making money. Having had cancer and discussing my options, Insurance pays for the protocols they set that treat the majority the same. Just because something is not covered under your insurance it does not mean it is unnecessary it just means it is not covered. In my case what was covered was not right for my tumor. The hospital was not going to run the test I needed because it was not covered by my insurance and it was 4400. They wanted to be paid. I asked are you treating my insurance or are you treating me?
Run the test!! Turns out they would have done a procedure I did not need that would not have helped me. I can not stress enough you need to be your one advocate do your research. We are not all the same, the standard protocols may not be the best treatment for your situation.
Insurance was not created to prevent illness, get to the root cause or cure your illness. It pays the minimum, treats symptoms once they present themselves and hopes you won’t use it.
We pay for so much insurance just in case some catastrophic happens. We work most of our lives. Our biggest expenses are for Insurance and taxes. So Knowing your insurance and getting the most out of it is to your advantage.! You only get one body. If you don’t care for it you will spend your wealth getting back your health. It is hard to get an appointment these days. Not sure where to start. Health starts with how you breathe and the condition of your mouth. See you dentist cavities and gum disease are warning signs something is out of balance in your body.
You will pay one way or another. You are paying for insurance! Use it!
A healthy Mouth is a healthy body and a happy healthy life.
Resources:
https://www.ramseysolutions.com/insurance/hmo-vs-ppo
https://www.webmd.com/health-insurance/hmo-vs-ppo
