Dental insurance works a little different than medical insurance. For instance, an individual dental PPO plan has waiting periods, annual maximum amount of coverage, etc.
Here is an example of an HMO Dental plan vs. PPO Dental plan:
Summary of Benefits for an HMO Plan
Deductible per calendar year per person: $0
Maximum per calendar year per person: $0
Office visit: $10
Exams: $0
X-Rays $0
Cleanings $20
Fillings $25-$120
Root canals $240-$400
Gum treatment $65-$650
Extractions $30-$230
Denture repair $55
Crowns $325-$495
Orthodontics $2600-$2800
Disclaimer: This is only a summary of benefits subject to the limitations and exclusions of the plan. Actual copayment amounts vary by plans and specific procedure(s).
Dental PPO
Summary of Benefits for a PPO Plan
Description
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Plan Pays Year 1
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Plan Pays Year 2
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Plan Pays Year 3
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Diagnostic and Preventative Procedures
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Diagnostic: Routine periodic examinations once in a 6 month period. Preventative: Dental prophylaxis (teeth cleaning) once in a 6 month period. Radiography: Bitewing and full mouth x-rays.
|
60%
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80%
|
100%
|
Basic Procedures (6 month waiting period)
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Restorative: Amalgam fillings. Other: Space maintainers, recementation of crowns.
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50%
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65%
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80%
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Major Procedures (12 month waiting period)
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Endodontics: Pulpal therapy and root canals. Periodontics: Treatment of diseases of the gums. Oral Surgery: Extractions and other oral surgery, including pre and post operative care. Prosthetics: Gold restorations, crowns, bridges, partials and complete dentures. Other: Pontics, repair of crowns and bridges, repair of full and partial dentures.
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0%
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30%
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50%
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Orthodontia
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This plan does not have any benefits for orthodontia.
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0%
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0%
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0%
|
Dental HMO or Prepaid Plans
Dental Health Maintenance Organization (DHMO) plans, also referred to as pre-paid plans, require you to choose one dentist or dental facility to coordinate all of your oral health needs. If you need to see a specialist, your primary care dentist will refer you; specialty care may require preauthorization.
A typical DHMO-type plan doesn't have any deductibles or maximums. Instead, when you receive a dental service, you pay a fixed dollar amount for the treatment (a "copayment"). Often, diagnostic and preventive services have no copayment, so you pay nothing for these services. However, generally if you visit a dentist outside of the network, you may be responsible for the entire bill. These plans can be a very affordable option for individuals and families
Dental PPO Plans
Dental PPO (Preferred Provider Organization) plans offer a network feature and usually offer a balance between lower costs and dentist choice. PPO dentists participate in the network thereby agreeing to accept contracted fees as payment in full rather than their usual fee for patients with the PPO. When you visit a PPO dentist, you typically pay a certain percentage of the reduced rate (called coinsurance) and the plan pays the rest. The percentage usually varies by the type of coverage such as diagnostic and preventive, major services, etc. For example, preventive services may be covered at 80% (you would pay 20%), while crowns and bridges may be covered at 50%. PPOs usually require you to meet a deductible and have an annual maximum amount of coverage (example: $1,000 per year).
While you typically have the lowest out-of-pocket costs if you visit a PPO dentist, the plan allow you to visit the dentist of your choice, even if she is not in the network.
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