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PPO vs DHMO dental insurance plans

From co-pays, to annual maximums, to your network of dentists, PPOs and DHMOs offer different cost and coverage options.

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There are two main types of dental insurance: PPO and DHMO. From co-pays to annual maximums to your network of dentists, each plan offers its own unique advantages and disadvantages for cost and coverage options to help suit your needs.

What is a PPO dental plan?

In dental insurance, PPO stands for Preferred Provider Organization, which is a medical arrangement in which dentists and an insurer have an agreement to provide services to subscribed clients at reduced rates. Unlike a DHMO, a PPO has a much wider network of dentists you can visit. A PPO is also more likely to offer reimbursement for services from an out-of-network dentist. Here's how a PPO plan typically works:

Choosing a dentist

Members on a PPO dental plan are incentivized to visit an in-network dentist, as those who visit an in-network dentist will not be charged more than the contracted rate even when the dentist's normal rate is higher. An added benefit of using an in-network dentist is that you won't need to submit any claim forms. The in-network dentist submits all dental claim forms directly to your insurance company on your behalf.

When you choose to see an out-of-network dentist. Your insurance company will only pay a certain standard amount, calculated according to the requirements of your state and you will be responsible for the difference.

What your insurance company pays

With a dental PPO, your insurance company pays a percentage of dentist's charges by category of service (e.g. preventive, basic, major). You are responsible for the remainder of the dentist's charges.

Waiting periods

A waiting period is the time period following your coverage start date during which no benefits are paid. Some PPO plans have no waiting periods for preventive care1, such as cleanings, exams, and x-rays. Basic services, such as fillings and simple extractions, and major dental work, such as root canals, crowns, implants, and kids’ braces, may have waiting periods of six to 12 months, depending on your state.

Deductibles and maximums

A deductible is the dollar amount that you’re responsible for paying before the insurance plan will start to pay benefits. Some individual dental PPO plans don’t require a deductible for preventive care if you use an in-network dentist. 

What is a DHMO dental plan?

DHMO stands for Dental Health Maintenance Organization, which means dentists contracting with an insurer  or health plan agree to accept an agreed upon fee schedule which results in their patients enjoying a reduced cost for services as an in-network dentist. Patients are required to choose a primary care dentist from an insurer’s network of dentists. Here's how a DHMO plan typically works:

Choosing a dentist

You must choose one in-network dentist from the smaller DHMO network who will serve as your primary care dentist.

If you do not choose a primary care dentist, a dentist in your area will be assigned to you. All care must be provided or arranged by your primary care dentist. There is no out-of-network coverage.

What your insurance company pays

DHMO plans like Guardian’s pay the difference between the total cost of dental services and your office visit charge plus the copay. You pay a small office visit charge plus a copay amount associated with each type of covered treatment

With a DHMO program, you know exactly what you will be responsible for paying before you visit the dentist. There are no claim forms you have to submit.

Waiting periods

A waiting period is the time period following your coverage start date during which no benefits are paid. There are no waiting periods in many DHMO plans.

Deductibles and maximums

A deductible is the dollar amount that you’re responsible for paying before the insurance plan will start to pay benefits. There are no deductibles in many DHMO plans. There also may not be a maximum dollar payout for each benefit year.

DPPO vs. DHMO: Which may be better for your situation?

If you’re shopping for dental coverage or are looking for a new plan, you may not know which plan options will work best for you and your family. Like regular health insurance, dental insurance offers different plan options to suit your coverage needs. Two of the most common dental insurance plans are dental PPO plans and DHMO dental plans.

From co-pays to annual maximums to your dentist network, each plan offers their own unique advantages and disadvantages for cost and coverage options to suit your needs. Read our full HMO vs. PPO comparison for more information.

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Sources:

1. https://www.investopedia.com/articles/personal-finance/122315/6-dental-insurance-plans-no-waiting-periods.asp Last accessed November 2019

Brought to you by The Guardian Life Insurance Company of America (Guardian), New York, NY. Material discussed is meant for general illustration and/or informational purposes only and it is not to be construed as tax, legal, investment or medical advice.
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