The short answer
A dental PPO gives you more choice of dentists and pays part of each bill, up to a yearly limit. A dental HMO usually costs less each month, but you must use dentists in its list, and it gives you less freedom.
If you want to pick your dentist and your specialists, a PPO is usually the better fit. If you want the lowest monthly cost and you are happy with a dentist from the plan's list, an HMO can make sense. Here is how the two work.
What a dental PPO is
PPO stands for preferred provider organization. The plan has a network of dentists who agreed to set prices. You can see any licensed dentist, in or out of the network. Delta Dental explains that you pay less if you choose a dentist in the network.
A PPO usually has a monthly premium, a deductible and a yearly maximum. Most PPOs follow the pattern that MetLife and Humana describe: 100% for preventive care like cleanings, 80% for basic work like fillings, and 50% for major work like crowns and bridges, once you have met the deductible. Some plans change these percents, so read yours.
You do not need to choose a primary dentist, and you do not need a referral to see a specialist.
What a dental HMO is
HMO stands for health maintenance organization. Some companies call it a DHMO, a DMO or a "managed care" plan. You pick one primary dentist from the plan's list. That dentist handles most of your care, and you need a referral to see a specialist.
Delta Dental notes that these plans can be more affordable, but they require you to see in-network dentists. Most only cover out-of-network care in an emergency or where the law requires it.
HMO plans often have lower premiums and no deductible. Many list a flat copay for each service, such as a set fee for a filling or a crown, instead of a percent. Humana says a typical dental HMO has no yearly maximum on covered benefits. Your plan's fee list will show the amounts.
Side by side
Here is how the main points compare in a typical plan. Details vary by company, so use this as a guide, not a rule.
- Choice of dentist: PPO lets you go in or out of network. HMO requires an in-network dentist.
- Monthly cost: PPO premiums are usually higher. HMO premiums are usually lower.
- Deductible: PPO often has one. HMO often does not.
- How you pay: PPO pays a percent of the bill. HMO uses set copays.
- Yearly maximum: PPO has one. HMO typically does not.
- Specialists: PPO needs no referral. HMO usually needs one from your main dentist.
Which one fits you
A PPO fits you better if you already have a dentist you like and want to keep. It also fits if you may need specialists, such as a gum doctor or an oral surgeon, and you do not want referral steps.
A PPO can also be helpful if you travel, or if you split time between cities, because you are not tied to one small list of offices. The tradeoff is the yearly limit. If you need a lot of work in one year, you may run out of benefits.
An HMO can fit you if you want low, predictable costs and you do not mind using the plan's dentist. It can also work well for people who need a lot of work, because there may be no yearly cap. A copay schedule makes it easy to see the price of a treatment before you start.
The tradeoff is less choice. If your dentist leaves the network, you may need to switch. If you want a service your plan does not list, you may pay full price. Check that the offices near you take the plan, and ask how long it takes to get an appointment.
A quick way to choose, with an example
Try this simple test. Add up what you expect to need this year: two cleanings and exams, and any known work like a crown or a filling. Then compare two numbers for each plan: the premium you pay for the year, plus what you would pay for that work.
Do the math for both a quiet year and a busy year. A plan with a low premium and high copays can cost more if you need a lot of care. A plan with a high premium may not pay off if you only need cleanings. If your job offers a plan, ask how much of the premium your employer pays, since that often changes the answer.
Last, do not buy a plan because of one big treatment without reading the waiting periods. Many plans make you wait six to 12 months for major work, as Humana's standard plan listing shows.
Say Plan A is a PPO with a $40 monthly premium, and Plan B is an HMO with a $20 monthly premium. In a quiet year you have two cleanings and exams. The PPO pays 100% of those, so you pay $480 in premiums and nothing at the visits. The HMO has a small copay per visit, say $10, so you pay $240 in premiums plus $20, or $260. The HMO wins.
In a busy year you also need two crowns. The PPO pays 50% after a deductible, up to its yearly limit, and you pay the rest. The HMO may charge a flat copay for each crown. The gap can swing the other way. These numbers are not real prices. They show why you should run your own numbers with each plan's fee list.
Families, kids, and whether you need a plan at all
If you cover children, look for plans that list orthodontics, sealants and fluoride. Those items vary a lot. Some PPOs pay a percent of braces up to a lifetime limit. Many HMOs list a flat fee. Also ask if the plan covers dental checkups every six months, since that is a common rule for kids and adults.
Not everyone does. If you only need a cleaning and exam twice a year, the premium can cost as much as the visits. Some people pay out of pocket, use a dental savings plan or set money aside in a health savings account if they have one. Others value insurance because it nudges them to go to the dentist and gives them peace of mind. Both choices are fine. What matters is that you do not skip care because of cost.
Working with KDA
At Kendall Dental Associates (KDA), we accept most dental insurance plans, and financing is available. Plan names and networks change, so please call us with your plan's name and we will tell you how we can work with it before you decide.
We are at 8833 SW 107th Ave, Miami, in the Kendall Mall, and our phone is 305-271-1421. Our hours are Monday to Friday, 8:00 AM to 5:00 PM. For dental emergencies, we offer emergency care 24/7.
Common questions
What is the main difference between a dental PPO and HMO?
A PPO lets you see any dentist but pays less if the dentist is out of network. An HMO requires you to use dentists from its list.
Which is cheaper, a dental PPO or HMO?
HMO premiums are usually lower. But your total cost depends on how much care you need and on copays or percents.
Does a dental HMO have a yearly maximum?
Many do not. Humana describes a typical dental HMO as having no yearly maximum on covered benefits. Check your own plan.
Do I need a referral to see a specialist?
With a PPO you usually do not. With an HMO you usually need one from your main dentist.
Can I keep my dentist if I switch plans?
Only if your dentist takes the new plan. Ask the office before you enroll.
This article is general information, not medical advice. Your dentist will confirm what is right for you at your exam. General information checked against: deltadental.com, humana.com, uhc.com, humana.com.