Dental coverage is not mandatory for insurers, resulting in many individuals lacking dental insurance. However, dental care plays a vital role in your overall health, and various options are available. Dental insurance can be obtained through the Marketplace, employers, Medicaid/CHIP, Medicare and private insurers. The primary types of dental plans mirror those found in medical insurance and encompass PPO, HMO, EPO, POS and indemnity plans.
Knowing the differences between PPO, HMO, EPO, POS and indemnity plans can help you make informed decisions about coverage, ensuring you receive the dental care you need.
There are multiple avenues to explore when seeking dental coverage, including through the Marketplace, employers, Medicaid/CHIP, Medicare or private insurers.
Compared to health insurance, dental plans generally come at a lower cost, allowing patients to prioritize oral health without breaking the bank. Despite this, 34% of adults go without dental insurance.
Dental Health Maintenance Organization (HMO)
HMOs (Health Maintenance Organizations) are dental insurance plans that share similarities with their medical counterparts. They offer a mix of benefits and drawbacks, making them a suitable choice for certain individuals.
Benefits of HMO dental plans include:
- Often low or no deductible
- Lower premiums
- Coverage for preventative care like cleanings, exams, X-rays, etc.
- Often no annual maximum
However, there are some limitations to consider:
- Typically requires choosing a primary dentist
- No out-of-network coverage
- Smaller provider networks
- Referral required for specialist visits
HMO plans are well-suited for those who prefer low premiums and don't mind having a limited network or choosing a primary dentist. It is important to note that these are general characteristics, and each HMO plan may have variations in coverage and network options.
Many dental terms mirror health insurance terms. Consider the following:
- Premium: Amount paid for insurance coverage.
- Deductible: Amount individuals must pay out-of-pocket before the insurance starts covering costs.
- Coinsurance: The percentage of costs shared between the insured individual and the insurance company.
- Copay: Fixed amount individuals pay for certain services.
- MOOP (Maximum Out-of-Pocket): The highest amount individuals have to pay for covered services in a given year.
However, a few terms unique to dental insurance include:
- Waiting period: Time to wait before certain services are covered.
- Limitations: Restrictions on coverage for specific treatments or services.
- Annual maximum: Maximum amount the plan will pay for dental expenses in a year.
Dental Preferred Provider Organization (DPPO)
DPPOs (Dental Preferred Provider Organizations) are the most common type of dental insurance plan. The national average cost of dental PPO coverage is around $350 to $500 per year. PPOs provide a network of dentists to choose from, offering flexibility in selecting a preferred provider. While you can go out of network with a PPO, it generally results in higher costs.
Benefits of DPPO (Dental Preferred Provider Organization) plans include the following:
- Flexibility to choose from a network of dentists
- No requirement for a primary dentist or referrals
- Coverage for preventative care
- Potential for lower out-of-pocket costs within the network
- Going out of network can be more expensive
- Premiums can be higher compared to other plan types
- Limited coverage for out-of-network providers
If you prioritize choice and flexibility in selecting dental providers and are willing to pay slightly higher premiums for these benefits, a dental PPO plan can be a good option for you.
Dental HMOs (DHMOs) and Dental PPOs (DPPOs) operate similarly to their medical HMO and PPO counterparts. The national average cost of dental HMO coverage is around $200 per year, making it generally less expensive than DPPO plans.
Similarities between HMOs and PPOs:
- Both HMOs and PPOs are types of managed care plans.
- They offer coverage for a range of dental care.
- Both require individuals to pay premiums and often involve cost-sharing in the form of deductibles, coinsurance, and copayments.
- Both HMOs and PPOs may have networks of preferred providers.
Differences between HMOs and PPOs:
- HMOs usually require individuals to choose a primary care dentist; PPOs do not.
- HMOs typically necessitate referrals from the primary dentist for specialist visits, while PPOs do not.
- HMOs usually offer limited or no coverage for out-of-network care, while PPOs allow for partial coverage for out-of-network care.
- Tend to have lower premiums compared to PPOs.
- PPOs provide a larger network of dentists to choose from.
Dental Exclusive Provider Organization (DEPO)
The national average cost of dental EPO (Exclusive Provider Organization) coverage ranges from approximately $250 to $450 per year and typically offers coverage exclusively for in-network services. When receiving care within the network, individuals experience minimal to no out-of-pocket costs, even for services beyond preventive care.
DEPO plans often have an annual maximum, a deductible, and waiting periods. Referrals are not required as long as the chosen provider is in-network. It is important to note that DEPOs do not provide coverage for out-of-network services. The coverage for routine dental services, basic dental care, and major work may vary depending on the specific plan.
Marketplace dental plans are mandated to include pediatric dental essential health benefits (EHB), covering basic and major care, prevention and medically necessary services. However, these essential benefits are not included in adult plans.
For adults shopping for dental coverage, a good dental plan should have:
- An accessible network of providers.
- Reasonable rates.
- High maximum coverage limits or no limits at all.
- Little to no waiting period for coverage to begin.
Dental Point of Service (DPOS)
DPOS (Dental Point of Service) plans combine elements from both DHMO and DPPO plans, offering a middle ground between the two. The average cost of POS coverage is approximately $300 to $500 per year. However, it is worth noting that the Centers for Medicare and Medicaid Services did not list any POS plans in 2023, suggesting their limited popularity.
DPOS plans typically require individuals to select a primary dentist and obtain referrals for specialist visits. While out-of-network providers may be seen, prices will be higher compared to in-network providers. DPOS plans are suitable for those who value flexibility in choosing providers but are willing to pay higher costs compared to regular DHMO plans.
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Dental Indemnity Plans
Indemnity plans, also known as traditional plans, provide individuals with maximum flexibility in choosing dental providers. There is no network restriction, allowing you to see any dentist you prefer. The average cost of indemnity plans can range from $400 to $700 per year. These plans typically involve a deductible and coinsurance, meaning you'll have to pay a portion of the costs.
Unlike other plans, indemnity plans do not require a primary dentist or referrals. However, the freedom and flexibility offered by indemnity plans come at a higher cost compared to other types of dental insurance. Indemnity plans are a good choice for individuals who prioritize flexibility and are willing to pay a higher premium for it.
Is Dental Insurance Worth the Cost?
Determining whether dental insurance coverage is worth it depends on various factors, including the specific plan and individual circumstances. For example, if a patient only requires routine cleanings and basic care, the premiums and copays associated with dental insurance may exceed the cost of paying out of pocket. However, individuals who anticipate needing extensive dental work or have recurring dental issues may find that the savings from dental insurance outweigh the plan's cost. It's important to note that certain services, such as orthodontics, are often not covered by dental insurance, and emergency services are often covered by health insurance.
Before making a decision, consider the annual maximum, which sets a limit on the company's coverage. Additionally, individuals should take into account any waiting periods imposed by the plan before accessing certain services. Ultimately, the choice of whether to get dental insurance is personal. If you can secure an affordable employer plan or expect to require multiple services, dental insurance may be worth it. However, in other cases, paying out of pocket can be a more cost-effective option.
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About Brenna Kelly, Licensed Health Insurance Agent
- American Dental Association (ADA). "Dental coverage, access & outcome." Accessed June 5, 2023.