Maximizing Your Benefits With Dental Insurance

Your dental insurance plan will have specific rules and limitations, such as frequency limits (usually two cleanings per calendar year) or time limits on particular procedures. These limits are designed to prevent excessive use of the benefits a consumer will receive.

PPO plans typically have more extensive networks of providers and offer more flexibility than DHMOs, including the ability to switch dentists without a referral and the option to see a specialist without one.

You Can See Any Dentist

Whether you have insurance or not, finding a dental practice that makes you and your family feel safe, comfortable, and treated well will make you more likely to visit regularly. Many dental practices, including Making You Smile, offer a wide range of PPO and other employer-sponsored plans.

The rules of a particular insurance plan are decided by the policyholder’s employer (or themselves, if they purchase the policy directly) and the insurer. These rules include the deductible, copayments, and limitations used to determine how much a given procedure will cover.

While HMOs and DHMOs require patients to visit in-network dentists for coverage, a PPO allows you to choose any dentist you want. However, your out-of-pocket costs will be higher if you go to an out-of-network provider.

In-network providers have signed contracts with the insurance company to accept a lower fee for their services than their usual office rate. When you see an in-network dentist, the dentist will bill your insurance company based on the pre-negotiated reduced rate. As an in-network provider, Making You Smile will help you maximize your insurance benefits by billing at the pre-negotiated, discounted rate. You can also save more by visiting an in-network dentist because the dental office will receive the full insurance payment upfront instead.

You Have More Choice and Power Over Your Dental Care

A PPO plan usually offers a more comprehensive network of dental care providers than an HMO plan. This means you’re not restricted to a list of “approved” dentists (hence the name Preferred Provider Organization) as you are with an HMO plan. In addition, you won’t have to get a referral from your primary dentist before visiting an out-of-network provider.

Dentists who join a PPO network agree to charge certain rates to plan members.

When you choose a PPO insurance dental, you must know your maximum benefits so that you don’t exceed them and have to pay more out of pocket. You can do this by reviewing the explanation of benefits, or EOB; your insurance provider sends you after each visit.

Most PPO plans have an annual maximum, the amount the insurance company will pay for approved services and procedures during a year. Once you reach this limit, you’ll be responsible for any expenses that exceed this amount. These amounts will vary based on the individual plan, some plans have a higher maximum benefit limit. You should check your maximum benefit limits to know how much you can spend before visiting the dentist.

You May Save More on a PPO Plan

With a dental PPO plan, you can visit almost any dentist. However, you will usually save more money if you see in-network providers. These dentists have agreed to charge fees lower than the usual, customary, and reasonable (UCR) fee for a given service.

HMO plans have a smaller network and limit your choices for dentists. They also tend to have higher out-of-pocket costs and annual maximums. A yearly maximum is the amount the insurance company will pay for authorized services in a calendar year. After that, the policyholder will be responsible for all charges exceeding the maximum.

When choosing a dental insurance plan, consider the different costs of premiums, copays, and deductibles, as well as the maximum and out-of-pocket costs for each plan. Also, consider the amount of preventive care covered by each plan.

Many people get dental insurance through their employer. Others purchase plans individually, either through state or federal marketplaces or directly from a health insurance company. Whether you choose a DHMO or PPO plan, you can expect to pay a monthly premium and deductible before benefits kick in.

You Don’t Need a Referral

Preferred Provider Organization (PPO) plan is typically more flexible because it doesn’t require patients to select a primary care dentist or obtain a referral to a specialist. However, it still usually has a network of dental offices that have agreed to charge negotiated rates for covered procedures.

Depending on the specifics of the individual plan, there may be an annual maximum amount that the insurance company will pay for all authorized services in a given year. Some PPO plans also feature a “Maximum Rollover” option that allows the balance of unused benefits to carry over for future years.

While PPO plans offer flexibility in selecting a dentist, they may also come with higher out-of-pocket costs than DHMO dental plans. This is because HMO dental insurance requires that patients use in-network providers unless they need to see a specialist or have an emergency.

With a PPO plan, on the other hand, you can choose any dentist for routine procedures, and most of the time, there is no copay. For out-of-network dental services, the insurance will generally pay based on an industry concept called “usual customary and reasonable fees” (UCR) rather than the actual fee charged by the dentist. Depending on the details of the individual plan, there may be limits on how many out-of-network dental services can be provided in a given year.

Author Profile

The Editorial Team at Lake Oconee Health is made up of skilled health and wellness writers and experts, led by Daniel Casciato who has over 25 years of experience in healthcare writing. Since 1998, we have produced compelling and informative content for numerous publications, establishing ourselves as a trusted resource for health and wellness information. We aim to provide our readers with valuable insights and guidance to help them lead healthier and happier lives.