Nargiz I. Zadeh, DMD
General, Cosmetic, and Implant Dentistry
Mon-Thurs 8am-5pm

Everything You Need to Know About the Differences in Dental PPO and HMO Insurance Plans

August 20, 2021
|
Posted By: Dr. Nargiz I. Zadeh, DMD

Aside from looking for an experienced dentist, another important decision that you may need to make regarding your oral health is the dental plan that you choose. While considering your options, you will likely notice the letters “PPO” and “HMO” come up quite frequently. Let’s look at the unique distinctions between these two options and how they can impact your dental care.

 

Understanding PPO and HMO

Before you can make an educated decision on which plan is best for you, it’s critical that you understand exactly what is included in a PPO plan versus an HMO plan:

 

PPO

 

PPO, or Preferred Provider Organization, means that the insurance company that you have chosen already has a network of dentists to choose from. These dentists have a contract with the insurance company in which they agree to pay fees for their services that are set by the insurance company. So, for example, if a dental offices usual, customary and reasonable (UCR) fee for a cleaning for without insurance is $120, the contracted fee with the PPO insurance company could be $108.  Additionally, PPO plans provide you with the flexibility of using your benefit with any dentist, regardless of whether they are contracted with the insurance or not.  

 

HMO

 

HMO, or Health Maintenance Organization, means that you can only see a dentist that is within your approved network. If you see a dentist that is not contracted with your HMO plan, then you cannot use the insurance at all. If you experience a dental emergency or need to see a specialist, you still need to find someone that is an HMO provider.

 

PPO vs. HMO: The Differences

Now that you understand the premise of PPO plans vs. HMO plans, it’s important that you understand the critical differences between these two options:

 

Premium Costs

 

As mentioned, dental PPO plans have premiums that are based on a fee schedule set by the insurance company. These are usually more expensive than an HMO plan because the fee schedule is agreed to by the provider and the insurance company. A dental HMO plan, on the other hand, uses what they refer to as a “pre-paid design” which can mean that your premiums are usually the least expensive of all dental insurance plans. However, these premiums cover the bare minimum and patients typically need to pay an extra fee if they want to upgrade to a certain crown material or filling material. With a PPO plan, there are no upgrades, and the insurance covers all treatments at a percentage.

 

Provider Access

 

Whether you visit an in-network or out-of-network dentist, you will be covered with a PPO. The standard fees at a dental office for patients that are out-of-network can vary from being slightly to significantly more expensive than the in-network contracted fees. This all depends on how the plan is structured; good insurance plans tend to cover almost the same amount for in- and out-of-network dentists allowing patients the freedom to see a provider they feel most comfortable with.  

 

With an HMO, you are only covered when you visit an in-network dentist for your services. The easiest way to find an in-network dentist is to call your insurance company, or to use the provider’s portal to ensure that you will be covered when seeing them.

 

Deductibles & Maximums

A dental PPO requires subscribers to pay an annual deductible and has a calendar maximum of how much it will cover. The amount varies between the different insurance companies so be sure to check with your company or broker before choosing the plan.

 

HMO plans do not have any deductibles, nor do they have calendar maximums, but there is a certain dollar amount you must pay first before your insurance will start covering your treatment. You are only responsible for your copayment at the time of the services rendered. Also, make sure to read any exclusions or limitations to maximums that may exist in your policy.

 

Of course, we understand that not every patient can maintain dental insurance, and our office believes that this should never prevent you from receiving the care that you need. For this reason, we have created an in-office benefits policy that covers all your dental needs. If you have questions about our benefits program, make sure to ask us at or before your next visit.

 

Finding the right dental insurance can be tricky so be sure to check with your broker, or the insurance company to ensure that all the needs you have will be met with the plan that you choose. Additionally, make sure to contact your dental office before signing up with a plan to ensure that the broker’s information accurately pertains to your dental office. Sometimes, brokers can accidentally provide you with misleading information, so it’s always better to have multiple people review your plan before locking into a contract. Our team is always here to speak with you regarding the insurance options that we accept. Get in touch with us today and we can help you demystify the nuances of each policy.

 

Testimonial from Ashley, Satisfied Patient 

I recently went to see Dr. Zadeh and staff as a new patient. I honestly couldn’t fathom having a more positive experience, especially considering, I was after all, at the dentist. Everyone was quite friendly, the environment was simple but clean, and best of all, I felt they listened to everything I had to say. When it came time to my filling, I honestly didn’t feel a thing. Happy to finally have found a place that doesn’t try and convince me I need more work than necessary. This office, (for all intents and purposes) is fantastic. I’ll be back!