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

Knowing the differences between dental health insurance plans will help you pick the best one for your needs. 2 of the most common are dental health maintenance organization (DHMO) vs. a dental preferred provider organization (DPPO), which have several key differences, like cost and the flexibility to choose your preferred dentist or select dentists within a defined network.

Let’s take a closer look at the key features of DHMO vs. DPPO plans to help find the one that’s best for you. (Keep in mind: These are general features for each type of plan. You should always check plan specifics with your insurer before you enroll.)

What is a dental HMO plan?

A dental HMO plan, commonly referred to as a DHMO, is designed to help keep costs lower. Any out-of-pocket 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.

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

What is a dental PPO plan?

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.

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

Compare DHMO vs. DPPO

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.

Features DHMO DPPO Cost

Dental HMO plans typically have lower monthly premiums than comparable PPO plans

Dental PPO plans typically have higher premiums than comparable HMO plans

Out-of-pocket costs may run higher in a DPPO plan

Out-of-network coverage

Out-of-network visits are typically not covered

Out-of-network visits are covered, however, in-network visits may have lower out-of-pocket costs

Coinsurance (percentage of costs you and your plan share for covered services)

Yes, some DHMO plans may base benefits on coinsurance percentages

Yes, typically DPPO plans base benefits on coinsurance percentages

Deductible

DHMO plans typically do not have a deductible

DPPO plans typically have an annual deductible but some plans may waive it if you stay in network for preventive services

Copay

Yes, DHMOs typically include set copayments

Often there is minimal or no copayment for preventive and diagnostic care

Sometimes, depending on type of service

Annual maximum

No, most DHMO plans do not have an annual maximum

Yes, DPPOs include a maximum amount of annual coverage

Primary dentist required?

Under a DHMO plan, you may have to choose an in-network primary dentist for all your dental care needs. If you need to visit a dental specialist, your primary dentist must refer you to an in-network dental specialist

Dental PPOs do not require you to pick a primary dentist and you can visit any licensed dentist in or out of network. You won’t need referrals to visit specialists

You may pay less out-of-pocket for in-network dentists and specialist visits, compared to visiting an out-of-network dentist

Network Size

Smaller network. Out-of-network costs are not covered

Larger network

Out-of-network costs may be covered

Specialist Referrals

Referrals may be needed to see specialists

No referrals are required

How dental HMOs and PPOs are similar

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.

How dental HMOs and PPOs are different

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.

How to choose between dental HMO and PPO plans

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 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 cleaning, oral exams and X-rays are usually covered 100% by DHMO and DPPO plans.
  • Fillings, root canals and 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.
  • 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.

What’s better, DHMO or DPPO?

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.

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