141 Dental Studio

Fee-for-Service vs PPO vs HMO

This is a continuation of our dental insurance discussion. We all have dental needs, whether a full mouth rehabilitation or an exam, x-rays and cleaning every 6 months. But just like any product or service, it has a cost associated with it. So how can you pay for your dental treatment? There are several different ways:

FEE-FOR-SERVICE

The simplest way is to pay out of pocket just like you do when you go to a store or salon. You have a service performed, you pay for it. If you don’t have dental insurance, your dental office is not on your insurance panel or you just don’t want to use your dental benefits, more than likely this is what you will have to do. You may be able to pay as you go, make a payment arrangement or have treatment financed.

Pros:

  1. You can go to whatever dentist you want, no ifs, ands or buts.
  2. You don’t have to have a formal referral to a specialist-you can choose whomever you please.
  3. Your dentist may give you a courtesy discount if you pay for your entire treatment plan up front.
  4. You don’t have to wait for a pre-authorization from your dental benefits.

Cons:

  1. It costs more as you are paying your ENTIRE bill out of pocket.
  2. If you have treatment fees financed or on a payment plan and you do not pay the bill in a timely manner, you can and will incur penalties or be sent to collections.

PPO

The PPO, or Preferred Provider Organization (indemnity), plan is probably the most common type of dental insurance. With this type of plan you (the insured) pay the insurance company a premium-usually through payroll deduction-so that you are covered with their benefits. The insurance company may contract with dentists to be on their “panel”. The agreement is that the dentist will provide services to the insured at discounted fees and the company will encourage their insured to go to dentists on their panel. With the PPO plans you also have in-network and out-of-network coverage (that will be discussed in another post). Most insurance plans have a maximum on how much they will cover. The most I’ve seen has been $1000-2000 per year. Anything over that maximum for the year is an out of pocket expense or you can wait until the new year when your benefits start over (though I do NOT recommend this if you have work to get done).

Pros:

  1. You have lower out of pocket costs.
  2. You can choose whatever dentist you want*.
  3. You can choose whatever specialist you want* and without a referral.

Cons:

  1. Everything is NOT covered at 100%
  2. You may have to meet a deductible (a set amount you have to pay out of pocket before your dental insurance “kicks in”).
  3. The treatment fees may exceed your dental plan maximum.
  4. You dentist may not be a member of your panel so your out-of-pocket may be greater.
  5. Some treatment just isn’t covered.

HMO

This is a Health Maintenance Organization. It is also known as DMO, DMHO or capitation. Just like with a PPO, you pay a premium, however the biggest difference is that you have to select a dentist from a panel of dentists that accept your plan and you HAVE to go to that dentist. If you are on that dentist’s roster, the office cannot deny you an appointment because the office has agreed to have you as a patient (after becoming a patient of record, if other issues arise you can be dismissed from the practice-different topic all together). Also you HAVE to have a referral to a specialist. The premium is generally lower than the PPO premium and in most cases there is no lifetime maximum. The insurance generally has an agreement with a dentist in a similar manner as the PPO agreement, however they send a set amount of money to the dental office each month for each patient on the roster. This amount is usually not a lot. It may not even be enough to even cover the most basic service so the dentist will have to see more patients to make up for this loss in revenue. Because of this the dentist may have to spread out appointments or work on treatment a little at a time.

Pros:

  1. Lower premium than PPO.
  2. Lower out of pocket cost.
  3. No lifetime or annual maximum in most cases.
  4. You have a “guaranteed” dentist.

Cons:

  1. You may have to wait longer to get in to see your dentist.
  2. You don’t have the freedom to go to any dentist.
  3. You will need a referral to a specialist.
  4. A lot of dentists do not accept HMO plans.
  5. The office may be a little more crowded.
  6. Your dentist may not be on the panel and you will have to go elsewhere to take advantage of the benefits.

So, you know a little more about the different types of dental plans. I will explain a little more in future posts about exclusions, clauses, limitations, in-network and out-of-network. I hope this is helping a little. I know this makes you not even want to have teeth, but no I will NOT just take all your teeth out and make you a denture! 🙂

*Please see the post on in-network vs out-of-network.

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141 E 55th St, Suite 2B
New York, New York 10022

Tel: 212.262.2952
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Tuesday: 9:00am – 6:00pm
Wednesday: 9:00am – 6:00pm
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Friday: 9:00am – 5:00pm
Saturday: By Appointment

141 E 55th St #2B, New York, NY 10022 212.262.2952