HMO vs. PPO Dental: The 7 Main Differences

By Deborah Pinnock on Nov 5, 2024 @ 02:25 PM

Choose the right plan for you and your family!

Dental insurance is a great way to save money on dental procedures and maintain good oral health. However, with so many different plans available, it can be overwhelming to choose the right one.

Imagine you've done your research and narrowed down your dental benefit choices to an HMO or PPO plan. But here's the catch - do you really understand the differences between these two types of dental plans? This knowledge is crucial in making the best decision for you and your family. You might have sought advice from co-workers, friends, or family members, but it's essential to clearly understand it yourself.

Here are the seven main differences in the battle between HMO vs. PPO dental plans. These comparisons will allow you to confidently pick the right plan for you and your family.

Key Takeaways:

HMO plans have lower premiums, while PPO plans tend to be more expensive.
HMO plans require you to select a primary care dentist, while PPO plans offer more flexibility and choice of providers.
HMO plans cover services only from in-network providers, while PPO plans allow for both in-network and out-of-network providers with differing costs.
HMO plans have copayments for covered services, while PPO plans use a fee schedule and coinsurance.
HMO plans do not require filing claims, while PPO plans may involve filing your own claim for out-of-network care.
HMO dental plans do not have any deductibles. However, PPO dental plans do require you to pay an annual deductible.

1. Premium Cost

HMO dental insurance plans use a pre-paid design, meaning their premiums (the amount you pay) are typically the least expensive of all dental insurance plans.

PPO dental plan premiums are based on a fee schedule the provider and the dental insurance company agreed to, meaning they tend to be more expensive.

2. Primary Care Dentist

On HMO dental plans, the role of the primary care dentist is significant. You are required to select and be assigned to one. This dentist will be your main point of contact for all your dental needs. It's important to note that you can switch dentists once a month by calling your dental insurance company. Transfers are usually effective the following month. However, some offices may only see you once your name appears on their roster.

HMO dental plans can vary, though. Some have an open access network (like Solstice plans) that allows you to choose any in-network provider or dental specialist, regardless of whether they are your assigned primary care dentist. This can be beneficial if you need to see a specialist or prefer more flexibility in choosing your dental provider. With this feature, you're not limited to a single dentist, giving you more options and control over your dental care.

With dental plans, you're always in control. You're not tied to a primary dentist and can visit any provider. The best part? You can switch dentists anytime without any hassle. This flexibility and control reassure you that you can manage your dental care on your terms, giving you peace of mind.

3. Provider Access

HMO dental plans only allow you to receive coverage if you visit an in-network provider for covered services. An in-network provider is a dentist contracted with your dental insurance company. To find out if a dentist is in-network, you can call the insurance to verify or use their online portal to locate in-network dentists near you. This process is straightforward and ensures you can access the services you need without incurring additional costs.

On the other hand, PPO dental plans offer a different level of provider access. They also have a network of dentists, but you have more flexibility. You can choose to visit an in-network dentist, which typically results in lower out-of-pocket costs, or an out-of-network dentist, which may result in higher costs. This flexibility can be a significant factor in your decision-making process.

Even if you can go out-of-network, it doesn't mean you should every time. Using an in-network provider will save you money compared to seeing an out-of-network provider.

4. Payment

HMO dental plans mean you'll pay the specific fee (copayment) listed on your Schedule of Benefits to the dentist for covered services. A Schedule of Benefits is a document like a menu that lists all the procedures your plan covers and what you pay for each procedure. This document is a valuable tool for estimating out-of-pocket costs before visiting the dentist. It provides a breakdown of the costs for each procedure.

PPO dental plans are based on a fee schedule. This is an agreement with your dental insurance company to charge up to a certain dollar amount for covered services, from routine cleanings to root canals. So, you pay a coinsurance, which is a percentage of this negotiated fee, and the insurance company pays the rest of that negotiated fee. This fee schedule is a vital part of how PPO plans work, as it sets the maximum amount you'll pay for each service, giving you more predictability in your dental costs.

When you use an out-of-network dentist, your coinsurance is higher because that dentist does not have an agreement with the dental insurance company and will, therefore, charge their usual fee for all procedures. This means you may have to pay more out of your pocket for the same procedure compared to visiting an in-network dentist.

5. Claims

One of the great conveniences of HMO dental plans is that you don't have to worry about filing claims. Your network dentist will handle that for you. Out-of-pocket costs can be more predictable, depending on the service. Call your insurance company's customer service line if you ever have a claim issue.

PPO dental plans are trickier when it comes to claims. If you use a network provider, they will file claims for you. But you may have to file your own claim if you receive care from an out-of-network dentist.

6. Deductibles

The deductible is a specific dollar amount you must pay before the dental insurance carrier will pay toward your claims.

HMO dental plans do not have any deductibles. You are simply responsible for your copayment at the time you receive services.

PPO dental plans do require you to pay an annual deductible. The out-of-pocket costs vary between insurance companies and specific plans. Be sure to check with the dental insurance company or your insurance broker to identify your deductible before choosing a plan.

7. Maximums

HMO dental plans have no annual calendar maximums. The maximum amount a carrier will pay for dental care in the calendar year is the maximum. Members can use their benefits throughout the year to their advantage. Just read any limitations or exclusions that may apply to out-of-pocket costs.

PPO dental plans have an annual calendar maximum. Like deductibles, this amount varies between plans. So, ensure you understand your calendar maximum and can get the dental care you need without exceeding it to maximize your savings. The maximum is the highest amount your insurance will pay for dental care in a calendar year, so knowing this limit is essential to avoid unexpected costs.

It is essential to pick dental insurance that works for your family's needs and budget. If you want additional help understanding dental insurance, you can get your free resource about dental insurance waiting periods.