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Dental Insurance HMO (DHMO) & PPO FAQ

What dental insurance is better: PPO or HMO/DHMO? 

The short answer is PPO is much better if you need dental work. If you have a chance to get PPO insurance instead of HMO – DO IT!  This is the best way to save you money. 

And here’s why: 

There are two types of dental insurance: HMO and PPO. Most dental insurance brands have both types (Humana HMO & Humana PPO, Aetna PPO & Aetna HMO, Cigna HMO & Cigna HMO). Here at Affordable Dentistry of Coral Springs, we accept new patients with both types of dental insurance: HMO & PPO. However, not all of our new patients know the type of insurance that they are paying for, whether HMO or PPO and there’s a huge difference between them. 

 

When I googled “what is the best dental insurance HMO or PPO”, I was surprised. For some reason most websites say that HMO is the best option because your monthly payment is less, you have no deductible and you can’t run out of your maximum allotted per calendar year. However, it is worth pointing out that HMO pays very little per doctor visit and doesn’t cover additional costs associated with the visit. For example, if the cost of the crown is $XXX, HMO will only pay for the materials needed to build the crown, which is only a fraction of the cost, and not pay for the procedure, supplies, etc. Patients end up paying out of pocket for all the extra costs associated with the treatment. Yes, Dental HMO insurance is cheaper upfront, but in the end, patients end up paying a lot more out of pocket for the visit. With dental insurance, cheaper doesn’t mean better. Unfortunately, insurance websites are taking advantage of people by trying to sell them a cheap product that ends up costing people more. 

 

So what are the main differences between dental HMO and Dental PPO insurances?

PPO

(Preferred Provider Organization) is the most common form of insurance. They provide members with a list of participating dentists to choose from. The dentists on this list have agreed to a lower fee schedule, which provides you, the patient, with a greater cost saving. They also assist with insurance billing. Most companies pay 50% on major treatments (crowns, bridges, partials), 80% or basic care (fillings), and up to a 100% for preventative care (exams, x-rays, basic cleanings). Annual maximums generally range from $1,000 to $2,000.

HMO

Also known as capitated or prepaid insurance, was designed to provide members with basic care at the lowest rate. Participating providers receive a monthly capitation check for patients assigned to the office. This amount is only a few dollars and is intended to offset the administrative costs. HMOs generally don’t pay for services rendered. Fees are usually greatly reduced, but the patient is solely responsible for paying the doctor.

 

HOW DOES DENTAL HMO & PPO WORK IN REAL LIFE:

EXAMPLE HMO VS PPO DENTAL INSURANCE 

Let’s say you have a cavity and you are looking for a filling (regular filling classifies as a basic service).

PPO Insurance should cover around 70%-80% of basic service  (depending on the individual plan of your PPO insurance). So let’s say filling is $200 (not a fee schedule price), your insurance would pay the dentist $140 and you will be responsible to pay only $60. If your maximum is $2,000 per year, you can continue to get dental treatments up to that amount.  

With HMO insurance situation is totally different: Each dental HMO plan has a specific fee schedule (cost). So each dental procedure has multiple steps to accomplish it, but the HMO plan doesn’t account for all the extra steps needed. Like when you are buying a car, HMO pays for the car, but doesn’t pay for the wheels, tires, seats, mirrors, engine, paint, etc. So when your insurance agent tells you that each filling will only cost you $60 (per fee schedule), it doesn’t account for anesthesia (pain medicine), tool cleaning, application of desensitizing resin for cervical and/or root surface, and so on. 

Here is a simple example: llet’s calculate how much will be your total for your dental feeling with HMO dental insurance plan:

  • Filling $65 (fee schedule price)
  • Desensitizer $59
  • Adjustment $40  

Your total for one filling can be around $164.  And you should cross your fingers that your HMO plan covers white fillings, and not the metal (amalgam) ones. So your insurance agent may say “Oh yes, we cover fillings”, but you should read the fine print, as they might only cover one

filling per calendar year. So should you wait until next year to get your second filling done? A filling that is not repaired in a timely manner can become a root canal, which is a lot more costly. So while there is no yearly $ limit, there is likely a limit on how many procedures can be performed. 

So what do you prefer, $60 or $164?  

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The main idea of this article is to show our lovely South Florida community what is the best dental coverage for them. We want you to pay less for your dental treatment in our office. Here at Affordable Dentistry of Coral Springs, we prefer that your insurance pays for you, but you should get the right plan for it.  

Nothing is perfect in this world: Yes, the PPO plan has a deductible. Yes, the waiting period may apply. Yes, you will pay out of pocket after you use your maximum. But it is totally worth it to pay and in the end, it will be much cheaper than an HMO plan. We have many years of experience dealing with insurances, and we have treated thousands of patients, and we can tell you with certainty that if you have HMO, you will pay a lot more in the end. 

Here are some questions that you should ask your insurance agent before buying PPO DENTAL INSURANCE:

  1. What is the Maximum amount per calendar year? The bigger amount is better. A good maximum is close to $1500-$2000.
  2. Is there any waiting period? Ask for an insurance that has no waiting period. You don’t want to pay for your dental insurance and wait 6 months to use it, right? 
  3. How much is the deductible? $50-$100 is ok. You pay a deductible only once per calendar year. 

Take advantage of your dental insurance! Call Affordable Dentistry of Coral Springs, so that our staff can help guide you in selecting the best dental insurance for you. We know that it’s not simple to pick the right dental plan. Here at Affordable Dentistry of Coral Springs, we work with many dental insurances, every day for many years. We can share our knowledge and experience to help you to pick the right dental coverage. We can explain to you which insurance will cover deep cleaning, root canal treatment, part of a zirconia crown, and even dental implant. Call us now at (786) 440-4948 or you can chat with us online here.