Dental HMO vs. PPO: What's right for you?

It boils down to this: 

• Dental HMOs (also called DHMOs) tend to cost less, but you can only go to a limited number of dentists. 
• Dental PPOs (also called DPPOs) let you see any dentist, but plan tends to cost more.

Dentist choice matters to many people. You probably have friends or family members who are very particular about which dentist they go to. And they're not alone – when people find a dentist they like, they tend to stay loyal to him or her. Studies show that over 60% of working Americans have been going to the same dentist for at least three years, and 32% have been with the same dentist for ten years.¹ 

PPO dental plans from the major insurance companies tend to have large provider networks, making it easier to find network dentists you want to see. For example, the Guardian PPO network has more than 120,000 network dentists at more than 420,000 locations, including thousands of specialists, such as periodontists, pediatric dentists, and orthodontists. However, you don't have to use a network dentist – PPO dental insurance lets you go to any dentist and still have coverage. Nevertheless, it pays to go in-network because your costs will be lower. Also, preventive checkups and cleanings are almost always covered at 100%.

On the other hand, if cost is more of an issue for you, the monthly premiums for a DHMO plan will typically be lower. There's no deductible to cover before the plan starts covering treatment. Your out-of-pocket costs will likely be lower, too – most DHMO plans have co-pays for each procedure. Finally, while most PPO dental insurance plans have a "cap" or annual maximum amount they'll pay for treatment, most DHMO plans have no annual maximum. 

The downside to Dental HMO insurance plans is that provider networks are very limited – a fraction of the size of a good PPO network. Since there's no out-of-network option, you may have to travel farther to see a dentist -- and it likely won't be the one you currently see. 

While cost and choice are important considerations, before you settle on a dental insurance plan, you should also look at what the plan covers. Generally speaking, Dental HMO plans tend to provide comprehensive coverage; PPO dental plans have different tiers of plans (e.g., entry tier, mid-tier, and top tier) – so some plans are more comprehensive than others. Treatments and procedures are typically organized into four broad categories. Every dental insurance policy has a plan summary that spells out how much you'll be charged for each type of service. Those categories are: 

• Preventive care - Checkups, cleanings, and routine X-rays are usually covered 100% in both types of plans.
• Basic care - This includes services such as fillings, extractions, and non-routine X-rays. These are typically covered in a DHMO but may not be in lower-tier PPO plans.
• Major care - Coverage for bridges, crowns, dentures, and the like is often included in a DHMO or higher tier DPPO – but check the plan summary to be sure.
• Orthodontic treatment  - Braces and other types of teeth aligners may or may not be covered, even in an otherwise comprehensive plan. If this is important to you, look at the plan summary for specifics.

The way you receive care in a DHMO is, in many ways, similar to an HMO health insurance plan (also called a Health Maintenance Organization). When you sign up, you'll choose a Primary Dentist from your plan's list of providers. Depending on where you live and other factors, it may be hard to schedule an appointment with your first-choice network dentist. So if you want to be seen immediately, be prepared to look for a back-up. 

Once you choose your Primary Dentist, you always have to go through them to get dental services. So, if you need to see a specialist, you'll have to first get a referral from your Primary Dentist. As we've noted, standard preventive care in a DHMO plan is typically covered at 100%, but other procedures are not. If you need basic or major care, you can expect to have a copay – a preset fee that is different for each procedure. For example, a filling might cost $50, and a crown $400, and there may also be a small fee paid for each office visit. However, there's typically no deductible and no annual maximum to complicate matters. Better yet, you won't have to deal with claims or wait for reimbursement from the insurance company. As long as you stay in the DHMO network, your dentist will handle it for you.

PPO stands for Preferred Provider Organization because even though you can see any dentist, the plan works better if you go in-network. If you already have a dentist you're comfortable with, it's a good idea to find out if he or she is in the plan before signing up. (Guardian lets you easily check online.) If that's the case, the dental care experience you receive will be similar to what it was before – just less expensive:

• Checkups and preventive services will likely cost nothing
• You'll pay much less for covered dental services and procedures

For example, if your dentist typically charges $100 for a filling when he or she is in-network, you might only be charged $65. But if fillings are covered at 70% (which is typical), you would only pay 30% of that as coinsurance. You pay $19.50, a total savings of over 80%. And like a DHMO, you won't have to deal with claims or waiting for reimbursement from the insurance company. If your dentist is in the DPPO network, he or she will handle that for you. 

Going out of network: You can go to any dentist and receive benefits. Dental procedures will be covered at the same rate – but without an initial discount. Also, non-network dentists might not submit the claim for you. In that case, you'd have to pay the $100 upfront, submit the claim, and wait to receive reimbursement from the insurance company. 

Deductibles, maximums, and waiting periods

Whether you stay in-network or not, you're likely to have a deductible of about $50 for an individual and $150 for a family. It will have to be paid out of pocket each year before the insurance company starts to cover services. Most policies also cap the annual maximum benefit amount, typically at $1,000 - $2,000 per member per year. Any dental expenses over the annual maximum are your responsibility. Finally, most PPO dental insurance plans -- and many DHMO plans — have a waiting period before they'll cover costly services such as root canals and crowns.

Is it important to see your current dentist?

If dentist choice is important to you, a PPO dental plan is likely your best option: they have more dentists, and there's a greater chance your dentist is already in-network. (Guardian has an online search tool that makes it easy to look up.) On the other hand, if you think most dentists are about the same – or if your current dentist is already in a DHMO plan – then that's a good option as well. 

How important is cost? 

Your monthly premiums and overall costs are likely to be lower with a DHMO plan. But if you want the freedom to choose any dentist, you can keep PPO insurance premium costs down by getting a lower tier (e.g., mid or entry tier) plan. 

What are your dental treatment needs?

If you've never had oral health problems, a DHMO or basic PPO insurance plan could work well for you. But if you or your spouse have had issues – or you have kids – then you should look into getting a DHMO or higher-tier DPPO plan that covers more types of procedures, including things like braces. 

Note: These plan design features are typical but may not apply to every policy

Where are you getting your plan?

If you can get dental insurance at work, that's probably your best choice for HMO and PPO plans. Employers get lower group rates because they are buying benefits for many employees at once. Compared to individual dental plans, group PPO dental often features higher coverage levels, and the company may pay a portion of the costs, making it an even better value. 

If you need to get coverage as an individual, that's okay too. There are plenty of affordable options, and it's easy to buy online. If you go to Guardian Direct, it only takes a couple minutes to get quotes and compare coverage details for three different tiers of coverage.

Is it better to have HMO or PPO dental?

Dental HMO vs. PPO: Either can be a good choice, but there are trade-offs with each type of plan. A PPO dental plan may have higher premiums, but it typically gives you a far greater selection of network dentists – and if it has a big enough PPO network, your current dentist could already be in the plan. An HMO dental plan usually offers lower monthly premiums, with no deductibles or annual maximums. But the networks are generally much smaller than a Dental PPO, so you may not get to see your current dentist.

What is an HMO dental plan?

These plans have a limited network, and you have to choose a plan provider as your Primary Dentist. He or she will refer you to a specialist if needed, but you always have to stay in the network for coverage. Basic preventive care such as checkups, cleanings, and X-rays are almost always covered with no copay, and depending on the plan's specifics, other types of basic and major services – from tooth extractions to crowns and root canals – may have a low, copay. A DHMO plan can also be a good choice for people who want dental insurance with no waiting period.

What is the difference between an HMO and PPO?

Both can help you maintain good oral health. The main differences have to do with flexibility and cost. If dentist choice is important to you – as it is to many people – PPO dental insurance offers an advantage: it typically gives you a much greater choice of dentists and your current dentist may well be in the plan’s network.

If savings are more important to you, then Dental HMO plans may have the advantage: premiums and out-of-pocket costs are typically lower, and while you will pay co-pays for many covered services, there are no annual maximums or deductibles.