Dental Insurance Information
PPO (Preferred Provider Organization) plans offer a network feature and usually offer a balance between lower costs and dentist choice. PPO dentists participate in the network thereby agreeing to accept contracted fees as payment in full rather than their usual fee for patients with the PPO. When you visit a PPO dentist, you typically pay a certain percentage of the reduced rate (called coinsurance) and the plan pays the rest. The percentage usually varies by the type of coverage such as diagnostic and preventive, major services, etc. For example, preventive services may be covered at 80% (you would pay 20%), while crowns and bridges may be covered at 50%. PPOs usually require you to meet a deductible and have an annual maximum amount of coverage (example: $1,000 per year).
While you typically have the lowest out-of-pocket costs if you visit a PPO dentist, the plan allows you to visit the dentist of your choice, even if she is not in the network.
HMO or Prepaid Plans
Dental Health Maintenance Organization (DHMO) plans, also referred to as pre-paid plans, require you to choose one dentist or dental facility to coordinate all of your oral health needs. If you need to see a specialist, your primary care dentist will refer you; specialty care may require preauthorization.
A typical DHMO-type plan doesn't have any deductibles or maximums. Instead, when you receive a dental service, you pay a fixed dollar amount for the treatment (a "copayment"). Often, diagnostic and preventive services have no copayment, so you pay nothing for these services. However, generally if you visit a dentist outside of the network, you may be responsible for the entire bill. These plans can be a very affordable option for individuals and families.
Fee-for-service plans, also known as indemnity or traditional plans, typically offer the greatest choice of dentists. Like PPO plans, when you visit a network dentist, you typically pay a certain percentage for each service (called coinsurance) and the plan pays the rest. The percentage usually varies by the type of coverage, such as diagnostic and preventive, major services, etc. For example preventive services may be covered at 80% (you would pay 20%) while crowns and bridges may be covered at 50%. Indemnity plans usually require you to meet a deductible and have an annual maximum amount of coverage (example $1,000 a year).
The difference between a fee-for-service plan and a PPO is that a fee-for-service dentist usually is not reimbursed at the same amount as a PPO dentist. This means you might also pay a bit more for your dental care.
Discount plans, or reduced-fee-for-service plans are not insurance but instead offer access to dental services at a discounted rate from participating dentists for a monthly or annual charge. There is generally no paperwork, annual limits or deductibles, but you must visit a participating dentist to receive the discount. Also, you may be responsible for a greater portion of the treatment cost than with a PPO or DHMO plan.