By Deborah Pinnock on Jan 4, 2017 @ 10:05 AM
You’ve finally narrowed down your dental benefits choices and have decided to either go with a dental HMO (DHMO) or dental PPO (DPPO) plan. And this is where it gets foggy. What’s the difference? Which is the best plan for you and your family right now? You’ve probably been talking with co-workers, friends or family members, trying to find someone to break it down for you. Well, here are seven differences between a DHMO and DPPO plan that will help you confidently pick the plan that’s right for you and your family.
Premiums on a DHMO plan typically are the least expensive of all the dental insurance plans.
The premiums for a dental PPO plan tend to be more expensive than a DHMO plan.
Primary Care Dentist
Often, with a DHMO, you must select and be assigned to a primary care dentist. You can switch dentists once a month by calling your insurance company. Transfers are usually effective the next month; however, even though the transfer may be effective, some offices may not see you until your name also appears on the monthly list they receive from you plan (i.e. a roster).
All DHMO plans are not the same though. Some have an open access network, like the Solstice plans, allowing you the freedom to choose any network provider.
You don’t have to be assigned to a primary care dentist but have the freedom to visit any dentist. And as for transfers, you can switch dentists at any time without having to call the insurance company or wait for your name to appear on an office roster.
You are only eligible for coverage if you visit an in-network provider for covered services.
With a DPPO plan, you receive coverage whether you visit an in-network or out-of-network dentist; however, you save more when you use an in-network provider.
You pay the specific fee (copayment) listed on your Schedule of Benefits to the dentist for covered services. A Schedule of Benefits is a document that lists all the procedures your plan covers and what you pay for each procedure; it’s similar to a menu.
An in-network dentist has made an agreement with your insurance company to charge up to a certain dollar amount for covered services. So, you pay a coinsurance, which is a percentage of this negotiated fee and the insurance company pays the rest of that negotiated fee.
When you use an out-of-network dentist, your coinsurance is higher because that dentist does not have an agreement with the insurance company and will therefore, charge his or her usual fee for all procedures.
You don’t have to worry about filing claims. Your network dentist will file them for you.
Once you use a network provider, they will file your claims for you. If you receive care from a non-network dentist, you most likely will have to file your own claim.
You pay no deductibles. (This is a specific dollar amount you must pay before the insurance carrier will pay towards your claims.) You are simply responsible for your copayment at the time you receive services.
You do pay an annual deductible. This amount varies by insurance company and by plan.
You have no annual calendar maximums. (This is the highest amount a carrier will pay towards your dental care in a specific period of time (usually January to December).
Members can use their benefits throughout the year to their advantage. Just be sure to read any limitations or exclusions that may apply to your plan.
You do have an annual calendar maximum. This amount varies by insurance company and by plan.
Would you like a handy guide so you can keep these differences in mind as you select dental insurance? Download our free DHMO/DPPO differences guide below or check out our DPPO/DHMO differences video!