• David Bryant

Dental insurance plan differences explained

Dental plans generally fall into a couple of key categories if purchased on your own or through your company-sponsored program, so how does choosing a PPO, HMO, or Indemnity differ?

PPO plans usually have larger numbers of providers available in the network. They work in and out of the plan network of doctors. They tend to be the most expensive and have annual limits on how much they cover in a given year. UCR and MAC define how the plan works when you use an out of network provider. UCR plans will be more expensive but will cover a Usual, Customary, and Reasonable amount when you go out of network, often they will pay the full amount up to what 90% (UCR 90th) of providers charge for that service in the area. MAC plans reimburse based on what an in-network dentist would have charged for that service. So if the in-network dentist charges $1,000 and then out of network dentist charges $1,000 it would be no problem, but if the in-network dentists can only charge $500 and it is covered at 50% then only $250 would be covered and you'd be left with a leftover bill of $750 for that service. Because of the predictability of fixed claims for the carriers, MAC plans tend to be less expensive.

Common structures look like 100% covered for preventative (cleanings and Xrays on a fixed schedule), 80% for basic (fillings sealants, etc), and 50% for major (root canal, crowns, etc)

Annual Caps for care are usually $500, $1,000, $1,500, $2,000, $2,500, $5,000 or unlimited ($5,000 and unlimited are still very rare!)

Prices usually range from $20 to $85 per person enrolled per month.

HMO plans are the least flexible and you must go to an in-network dentist to receive services. The upside here is that HMOs are the least expensive option and you will have copays for each service so you know exactly what your costs will be based on each American Dental Association code (ADA code). HMOs also have an added benefit of unlimited claims in a year that can be incurred and the carrier will continue to pay out its portion with no annual cap on your care.

Prices usually range from $8 to $40 per person per month

Indemnity plans offer a fixed cash amount to use at any dentist and provide no network discounts. The advantage is that you can truly go anywhere and you can know how much the insurance will cover but it's then up to you to cover the rest of the claim so these plans are best for people who like to negotiate directly with their dentists. These plans are usually priced very similar to PPO options ($20 to 85 per person per month) and have similar annual caps on how much they will payout.

Finally, we have discount dental plans. These are the cheapest for a reason. They often are nothing more than promotional discounts to use a certain list of providers. They can range in price from Free to $15 per person per month. In our experience, you could easily negotiate a similar discount of 5% to 25% with most dentists directly anyway, as a result, we do not encourage these plans unless they are free and cover the dentist you actually want to use.



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