Oral & Vision Health Blog

7 Differences Between a Dental HMO and PPO Plan

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. 

1. Premium Cost
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DHMO plan use a pre-paid plan design, meaning their premiums are typically the least expensive of all dental insurance plans.

DPPO plan premiums are based on a fee schedule agreed to by the provider and the insurance company, meaning they tend to be more expensive than DHMO plans 


2. Primary Care Dentist

DHMO plans often require you to 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 their roster. 

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All DHMO plans are not the same though. Some have an open access network (like Solstice plans) that allows you the freedom to choose any network provider.

DPPO  plans don't require you to be assigned to a primary care dentist. They give you the freedom to visit any dentist you want. And  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.


3. Provider Access   
DHMO plans mean you are only eligible for coverage if you visit an in-network provider for covered services. An in-network provider is a dentist who has been contracted with your insurance company. To find out if a dentist is in-network, you can call your insurance company to verify or use their online portal to locate in-network dentists near you. 

DPPO plans allow you to be covered whether you visit an in-network or out-of-network dentist. But it's worth noting that just because you can go out of network doesn't mean you should every time. Using an in-network provider on your DPPO plan will save you a lot of money compared to an out-of-network provider.


4. PaymentCash_Icon

DHMO 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 that lists all the procedures your plan covers and what you pay for each procedure; it’s similar to a menu. 

DPPO plans, as mentioned above, are based around a fee schedule. A fee schedule is 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.

5. Claims Billing_Icon

DHMO plans are convenient since you shouldn't ever have to worry about filing claims. Your network dentist will file them for you. And if you ever have an issue with your claim you can just call your insurance company's customer service line and they can help you! 

DPPO plans are a bit trickier when it comes to claims. As long as you use a network provider, they will file your claims for you.  But if you receive care from a non-network dentist, you may have to file your own claim. 


6.Deductibles  Balence_Icon

DHMO plans don't have any 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.

DPPO plans do pay an annual deductible. This amount varies between insurance companies and specific plans, so be sure to check with your insurance company or your insurance broker to identify your deductible before choosing a plan.


7. Maximums 

DHMO plans have no annual calendar maximums.  (This is the highest amount a carrier will pay towards your dental care in the calendar year). 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.

DPPO plans do have an annual calendar maximum. Like deductibles, this amount varies between insurance companies and by plans. So make sure you understand your calendar maximum and can get the dental care you need without going over it to maximize your savings.

Picking dental insurance that works for your family's needs and budget is an important part of your dental care. If you are looking for additional help understanding all your options before you buy, be sure to click the image below for a free consultation with a Solstice team member - we will help you pick the perfect plan for you! 

We can help you find the right dental plan.  Click here for more info!