Dental HMO vs. PPO insurance plans: What’s the difference?

A dental HMO plan, commonly referred to as a DHMO, is designed to help keep costs lower. Any out-of-pocket dental costs are usually pre-determined, and there is no annual maximum for covered benefits. DHMO plans tend to focus on preventive care and encourage regular dentist visits. These plans have networks of dentists under contract with the insurance company.¹

Benefits of dental HMO:

• Lower premiums than dental PPO
• No deductible
• Set copayments for covered services with little or no copayment for diagnostic and preventive care
• There is no annual maximum

Limitations of dental HMO:

• Smaller network of dentists to choose from
• You may be required to choose a primary care dentist from a pre-approved list
• To visit a specialist, you may have to get a referral from your primary care dentist
• Out-of-network costs not covered

A dental PPO plan usually has higher out-of-pocket costs and has a deductible, but allows greater flexibility to choose any dentist and usually does not require a referral to visit a specialist.

Like DHMOs, DPPOs have a network of dentists under contract with a dental insurance carrier. The patient can see dentists in network (which will usually keep costs lower), but has the freedom to choose dentists and specialists out of network.²

Benefits of dental PPO:

• Flexibility to choose your dentist or dental facility
• Larger network of dentists from which to choose
• No referral needed to visit a specialist
• Do not need to designate a primary care provider (PCP)
• May receive a partial reimbursement for covered services from out-of-network dentists

Limitations of dental PPO:

• Higher premiums than DHMO plans
• Will typically have a deductible
• Coinsurance only kicks in when deductible is met
• Typically has an annual coverage limit
• DPPO coinsurance or copayments may be higher compared to DHMO plans
• Out-of-pocket costs may be higher than DHMO plans
• To receive reimbursement, patients must file claims and there can be a waiting period

Here are the key features of typical dental HMO vs. dental PPO plans. Note, this information may not apply to all dental HMO or dental PPO plans.

Dental HMOs and PPOs are similar in that both offer dental care for patients.

• Both plans have networks of dentists under contract with the dental insurance company, which can help reduce your out-of-pocket dental expenses.
• An employer might offer a DHMO or DPPO plan to its employees. Patients and their families can purchase Individual DHMO or DPPO coverage without needing to go through their employer.

Dental HMOs and PPOs are different in many ways, but that doesn’t make one insurance plan better than the other. Patients should consider what’s most important to them when making their decision.

Generally, dental HMO plans require a primary dentist and only provide full coverage for in-network visits, but will usually have lower premiums than a comparable PPO plan.

Dental PPO plans tend to have higher premiums than dental HMO plans, but usually provide more coverage for out-of-network visits, and PPOs will not require you to select a primary dentist.³

Choosing a dental PPO vs HMO plan depends on the patient’s specific needs. DHMOs, though usually more cost-effective, are not necessarily better than DPPOs. Here are some reasons people select a dental HMO or PPO given their dental needs:

If you have a preferred dentist:

If you have an existing dentist or preferred dentist not in the DHMOs network, you may want to choose a DPPO.

If you need to see a dental specialist:

Under a DHMO plan you may need your primary dentist to refer you to a specialist in network, which may cause a delay. In a DPPO plan, you can choose a specialist without needing a referral.

If you expect to undergo major surgery:

A DHMO may be a better choice when planning to undergo major dental surgery because there’s no deductible nor annual maximum, but you should first determine if the procedure will be covered by your dental plan.

What procedures are typically covered by a DHMO vs. DPPO?

• Preventive services like teeth cleanings, oral exams and dental X-rays are usually covered 100% by DHMO and DPPO plans.
• Dental fillings, root canals and tooth extractions may be considered basic restorative care. Under a DHMO, these typically have a flat fee. Under a DPPO, you will first need to meet your deductible before paying a percentage of covered costs.
• Dental crowns, bridges, dentures and oral surgery are usually considered major restorative care. They may be covered up to a certain amount based on your plan’s terms.

Will I need to file claims?

If you don’t want the hassle of filing claims for reimbursement, a DHMO would be your preferred option. However, in-network PPO providers may also file claims for you.

It depends on your needs. DHMO plans are intended to be more cost-effective, while DPPO plans offer greater flexibility and a wider network in choosing your care. You should always research out-of-pocket costs for any plan and the limitations for each. If possible, consult your current dentist so you know what types of plans their facility accepts.

Knowing your unique needs will help determine the dental insurance plan that is best for you.