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| HMOs vs PPOs | ||
|---|---|---|
| HMO | PPO | |
| Premiums | Lower | Higher |
| Annual maximum | No | Yes |
| Deductible | Lower or none | Higher |
| Coinsurance | Flat, low rate (copayment) for services | Percentage coinsurance or flat copayment due for each procedure after you meet the deductible |
| Network | Must see in-network primary care provider. Networks are smaller | You can see a variety of providers, but reimbursement percentages may vary. Networks are larger |
| Referrals | Required | Not required |
Dental PPO Plans
Dental PPO plans, also called DPPOs, make up 86% of the commercial dental market, according to the National Association of Dental Plans. These plans charge higher premiums than HMOs but offer more flexibility when choosing a dentist or specialist.
Benefits and Limitations
DPPO pros include:
- Flexibility when choosing a dentist
- Larger dentist network
- No required referral for specialist care
- Partial reimbursement for out-of-network services
However, PPOs also have a few cons:
- Higher premiums
- Required deductible
- Annual coverage is limited by a cap
- Higher coinsurance and copayments
Choosing a Dentist and Specialist in a PPO
PPOs have a preferred dentist network but still cover you for seeing dentists outside of the network. With a PPO plan, you may be able to stick with your trusted, long-time dentist. You can also switch providers whenever you want and don’t need a referral to visit a specialist.
However, you receive the best reimbursements and lowest out-of-pocket costs by seeking care within the DPPO’s network.
PPO Coverage
PPO coverage typically includes preventive care, such as x-rays, cleanings, and exams. Depending on the plan, the PPO may also cover additional services such as fillings, crowns, root canals, and gum disease treatments.
Major PPO plan limitations concern waiting periods, said Peter Pinto, CEO at Deering Dental in Miami, Florida.
“A waiting period is a blackout period, usually six months to a year long, during which only basic services such as cleanings, exams, and sometimes fillings are covered,” he said. “Anything else you need will not be covered by your plan until the waiting period has passed.”
Note
Instead of waiting periods, some plans increase coverage percentages every year as a loyalty reward—for example, 50% cost coverage in the first year for a filling, 60% in the second year, and 70% in the third year.
PPO Cost
Typically, PPOs charge higher premiums than DHMOs. According to the NADP, individual DPPO plans cost around $35 per month.
Typically, you’ll get 100% cost coverage for preventive care. Every year, you’ll pay a deductible, which is a dollar amount (typically between $50 and $100) you must meet before your plan begins to pay for other services. The insurer will pay for those services either as a percentage of the cost—such as 50% or 60%—or as a flat payment.
PPO dental plans typically have an annual coverage limit, such as $1,000 or $1,500. After your covered claims reach this amount, the plan pays nothing else for the rest of the year.
Dental HMO Plans
Dental HMOs, also called DHMOs, encourage you to get regular dental check-ups by clearly defining your out-of-pocket costs. While they might fit your budget, DHMOs have a few shortcomings. Dental HMOs may also be known as managed care plans.
HMO Benefits and Limitations
On the plus side, HMOs offer:
- Lower premiums
- No annual maximum
- No deductible
- Set copayments
However, HMOs also come with a few drawbacks:
- Require you to select a primary care dentist
- No out-of-network coverage
- Limited dentist network compared to a PPO
- Require a referral for specialist care
HMO Network Restrictions
You must choose a primary care dentist from the HMO’s network of contracted providers. This dentist acts as a “gatekeeper” of sorts for your dental benefits.
“You have no benefits outside of your network,” Pinto said. “You may also have to get a referral from your dentist before being able to see a specialist.”
“Some dentists choose not to accept HMO plans due to lower reimbursement rates and the administrative complexities associated with these plans,” said George Beach, a Modesto, California-based insurance agent licensed to work in 14 states. “They may also prefer the autonomy and patient volume control offered by not being tied to a network.”
Sometimes, a plan may cover a non-network dentist who provides services during a dental emergency outside your home area. Check with your plan for details.
HMO Services Covered
Like PPOs, DHMOs usually cover 100% of the preventive services your selected in-network dentist provides. The plans also cover other traditional services such as fillings, crowns, and implants. These plans typically do not have a waiting period for any services, Pinto noted.
However, your DHMO may not cover some services and expenses, such as teeth whitening or upgrades to gold or porcelain for molar restorations. Or your dental HMO may limit how often you can get services.
DHMO limitations on non-network providers can be challenging if you need a specific specialist’s care for certain or more complicated dental services.
HMO Cost
“HMO plans are typically cheaper and have small co-pays, making dental care extremely affordable,” Pinto said.
DHMOs don’t have a deductible and cost only an average of almost $14 per month in premiums. HMOs require you to pay a flat copay for services. Preventive care is usually covered in total, or you might pay a flat fee such as $65.
You’ll pay a copay for all other services, such as $28 per filling. Dental HMOs rarely feature a plan maximum, and so may be a good fit if you don’t like the idea of maxing out your benefits.
Choosing Between PPO and HMO Plans
“When selecting a dental plan, consider individual needs and preferences, the importance of regular dental care, network restrictions, and cost savings,” Beach said.
“For example, if you frequently need specialist care or prefer a specific dentist who is out of network, a PPO might be more suitable despite higher premiums,” he said. “On the other hand, if cost-saving is a priority and you don’t mind network restrictions, an HMO could be a better choice.”
Consider these important factors when choosing dental insurance:
- Premiums: How much can you afford to pay every month?
- Per-Procedure costs: What are your potential copayment and coinsurance costs?
- Current and future dental care: Do you need to worry about waiting periods?
- Dentist: Do you wish to keep your current dentist? How many HMO-participating dentists are available in your area?
- Specialist availability: How many specialists are available?
Everyone’s dental needs are different. If you’re single, relatively young, and have few dental problems, an HMO plan might meet your needs while saving you money.
But, if you have a large family, you might need the flexibility of a DPPO plan. Or, if you have a long-time dentist you would like to keep, compare HMO and PPO network lists before enrolling to ensure your dentist would be available.
Try to anticipate your future needs. For example, if you’re heading into your golden years, you might need a plan that covers dentures in the foreseeable future. Or, if you have kids in middle school, you might opt for a plan that will cover orthodontic care.
As another alternative, you can ask dentists if they offer an in-house discount or membership plan that could save you more than an individual PPO or HMO insurance plan, Pinto suggests. Some dental insurance companies also offer dental savings plans that might be a better fit for you.
Note
All dental insurance plans have limits on coverage and lists of dental services that are not covered. If a dental service isn’t listed on a plan’s schedule of benefits, it likely is not covered at all. Review these limits before choosing a plan to understand what you’re buying.
The Bottom Line
HMOs and PPOs are two main types of dental insurance. HMO plans have lower premiums and copayments but restrict your care to the plan’s network of dentists and specialists.
PPO plans offer more flexibility with choosing your dentist but charge higher premiums, have higher deductibles, and impose annual coverage limits.
Choosing the right dental insurance for you and your family depends on evaluating your current and future needs. When comparing dental insurance, look beyond monthly premiums and select a plan that best balances benefits and costs.
FAQs
Why Would a Person Choose a PPO Over an HMO?
While HMO plans usually have lower premiums, many people opt for a PPO plan for the dentist and specialist choice. HMO plans may feature a smaller network of dentist choices and an inability to go outside of the dental network.
When shopping for dental insurance, it’s important to research each plan’s network of dentists before enrolling, especially if you prefer to continue service with your current provider. Also make sure the plan covers the procedures you may need, such as dental implants.
Which Type of Dental Plan is the Most Common?
DPPOs are the most common and account for 86% of the commercial dental policies in the U.S. market, according to the National Association of Dental Plans (NADP). In Investopedia’s list of the best dental insurance companies, we compared PPOs from the top providers.
Why Do Dental PPOs Have Higher Premiums Than HMOs?
“PPO plans have a better network of more experienced dentists and, in many cases, a better standard of care because their fees are closer to the real market rate for dental services,” Pinto said. “The higher cost of paying these more experienced dentists is why the premiums are higher.”