Insurance is complicated. In fact, only 12 percent of American adults are health literate. That means, employees have a lot of questions. And chances are, they are directing those inquiries to their benefits administrators, who are at times, overwhelmed. Here’s your opportunity to become their hero. Your extensive understanding of dental insurance, plus your knowledge about how the different dental plans work, makes you an amazing resource for employer groups. But it’s not enough to have knowledge. As a dental insurance broker, you must become an expert at breaking down complicated information in a way that makes it easy for your clients and their employees to understand it.
One of the questions employees ask their benefits administrators is, “What is a dental PPO plan?” Impress your groups with your ability to simplify this confusing topic, using these seven talking points.
First, we should define it, in case you’re asked.
A dental PPO plan (also called a DPPO) stands for Dental Preferred Provider Organization. It’s a plan that offers members both in- and out-of-network coverage. However, members pay lower costs when they utilize an in-network dentist. This is because in-network providers have made an agreement with the dental insurer to accept a negotiated fee as payment in full for each procedure instead of their usual fees.
Now that the definition’s out of the way, here are seven things you should know about this plan-- guaranteed to make you an expert for your client.
Premiums on a dental PPO plan tend to be more expensive than the various dental insurance plans available. Your client should keep the expense of this plan in mind if cost is a factor in their decision.
Members don’t have to be assigned to a primary care dentist but have the freedom to visit any dentist. They can also change dentists at any time without having to call the insurance company. Some dental HMO plans have a similar type of flexibility as a result of a feature called open access. It allows the member to go to any in-network dentist and switch offices as often as they wish within a calendar year, without waiting to be on a roster.
As mentioned earlier, with this plan, members can see both in-network and out-of-network dentists and specialists. This may be ideal for snowbirds, employees who have to travel frequently for business or companies that have multiple locations across the nation. It may also be a good solution for members who want coverage at an out-of-network dentist who does not want to join the insurer’s plan. This way, the member still gets coverage, although out-of-pocket costs will likely be higher.
On a DPPO plan, members pay a coinsurance amount, which is a percentage of the negotiated fee established between the plan’s network dentist or specialist and the insurance company. Keep in mind, when members use an out-of-network dentist, their coinsurance is higher because that dentist does not have an agreement with the insurance company and will therefore charge his or her usual fees for all procedures.
Members typically don’t have to file claims if they visit a network dentist; however, if the member uses a non-participating dentist, he or she will most likely have to file the claim.
Members have to pay an annual deductible before the insurance company will begin paying towards their claims. This specified dollar amount varies by insurance company and by plan.
With a DPPO plan, the insured has an annual calendar maximum. This amount also varies by insurance company and by plan. So, this type of plan may be fine for someone who does not need extensive work; however, for the member who does, the treatment cost may exceed their annual maximum, leaving them responsible for the balance.
In conclusion, your clients have questions and they are looking to you for answers. Their respect and value for you as their insurance broker grows as you are able to give them the informed answers they need to make right decisions. Understanding a dental PPO plan--a standard dental insurance product in the industry--will go a long way in solidifying in their minds that you are an indispensable resource in helping them maneuver the sometimes confusing world of healthcare.