Today, employers tend to offer employees either PPO, HMO or a choice between both a PPO and an HMO dental plan.
PPO plans allow individuals the ability to seek treatment from any dentist. Should treatment be obtained from a network provider the employees out of pocket costs are less, since those providers have agreed to a discount for their services. Employees incur a higher out of pocket amount for treatment from non-network providers since these dentists have not agreed to any discount.
The most popular plan designs typically cover preventative care at 100%, basic at 80% and major at 50%. Employees are responsible for any amount charged above what the plan allows plus the remaining percentage (i.e. 20% if the expense was paid at 80% by the plan.).
These plans have an annual maximum (amount the plan will pay out in claims during the calendar year, per person). They may also have a calendar year deductible (which may apply separately for network and non-network expenses). Preventive procedures consist of routine exams, teeth cleaning and basic X-rays. Basic procedures consist of routine fillings, Endodontics, Periodontics and oral surgery. Major procedures normally include Crowns, Bridges and Dentures. Orthodontia coverage may or may not be included.
Not all plans cover Endodontics, Periodontics or even Oral Surgery as a Basic procedure. Some plans have a waiting period before certain benefits are payable, Orthodontia may or may not be included.
A key area to determine is does your plan utilize a “schedule” or “Usual Reasonable & Customary and at what percentile” for expenses from nonproviders.
If your DDS tells you it will cost over $ 200 for your treatment, consider having a pre-determination form submitted to your carrier BEFORE any work is performed. That way, you and your DDS will know exactly what’s covered and how it going to be paid, to avoid any financial surprises.
HMO plans require an individual to obtain treatment only from a network dentist that they have elected to receive treatment from. There are no annual maximums or deductibles. There are copayments for each treatment obtained. Additionally, Orthodontia coverage is provided for both Adults and Children.
There are several other types of dental plans, such as DMO (similar to an HMO but usually have percentages payable rather than copayments), Indemnity Plans (similar in design to a PPO), which allows an individual to seek treatment from any provider.