If flexibility and choice of dentist are essential to you, a PPO plan is the right option. These plans typically have a more extensive network of providers, lower monthly premiums, and no deductible or annual maximum.
Dentists in a PPO network agree to charge a discounted rate for plan enrollees. This helps keep your dental costs low.
Choice & Flexibility
A quality PPO dental insurance plan provides more choice and flexibility regarding who you can go to for your care. Unlike an indemnity or traditional program that pays claims based on the usual and customary rate, PPO plans have a network of providers that negotiate with the insurance carrier to provide discounted service rates.
To lower service fees, the PPO plan typically has a deductible and coinsurance that you must meet before your benefits kick in. Depending on the type of service you need, these amounts can be as low as 20 percent or as high as 50 percent.
In addition, PPO dental insurance in California offers a vast network of dentists, providing flexibility and comprehensive coverage for various dental procedures, ensuring Californians have access to quality oral healthcare.
Another great thing about PPO dental insurance is that you can usually visit any provider within the network without a referral from your primary care dentist, and you can see a specialist without a referral. Many PPO plans also have annual maximums for the amount of coverage they will pay in a year, and you are responsible for any expenses exceeding this limit.
While most dental plans have maximums on their payments, it is essential to remember that most people will need primary restorative treatments like crowns, bridges, and implants. These types of therapies can add up quickly, so if you plan to have these kinds of procedures shortly, consider a higher-tier PPO plan with lower annual maximums or a dental HMO plan that will cover all expenses in-network.
Savings
PPO dental plans typically offer a more extensive list of dentists than HMO plans and often feature a network of preferred providers that provide discounted rates for plan members. These provider networks use a standardized fee schedule that the insurance company negotiates with them, so you know beforehand what to expect. This provides a level of certainty that helps with budgeting and avoids unexpected costs.
Most dental insurance plans have an annual maximum of how much the insurer will pay for services in a year. Everything you spend on out-of-pocket dental costs will count toward this maximum, so it is essential to stay within it.
Some dental plans have a deductible that you and your insurance company will split. For example, if you need $200 worth of services and still need to pay your deductible, you will have to pay the first $20, and then your insurance company will cover the remaining $80. This is an excellent reason to choose a dental insurance policy with the lowest possible deductible.
While PPO plans can provide flexibility, they tend to have a higher premium than HMO plans. eHealth has a wide variety of dental procedures to meet the needs of individuals and families, including PPO, DHMO, and dental discount plans that eliminate many of the traditional insurance complexities.
Preventive Care
In addition to covering routine preventive visits (like cleanings and checkups), a dental PPO can help offset the cost of more costly procedures. This is because many PPO plans have an annual maximum limit on what they will pay for covered dental services. These limits are negotiated between an employer and the insurance company or directly with a consumer.
Plan enrollees need to know how their PPO’s cap works because they may be responsible for the entire cost of any care over that maximum.
Dental PPO plans typically offer a more extensive network of dentists than HMO options, though exceptions exist. In the health insurance market, most people looking at individual medical coverage are coming off Small Group benefits (directly or as a dependent), where there is usually a dental benefit built into the plan.
Dental PPOs also allow plan enrollees to choose their providers, though they may be more likely to save money using in-network dentists. This is because a dental PPO’s provider network is pre-negotiated, and the insurance company pays less than they would for an out-of-network visit. Most of the time, in-network providers will submit claims to the insurance company on behalf of their patients. When the claim is paid, a receipt called an Explanation of Benefits (or EOB) is provided to the member detailing what was covered and by how much.
Specialty Care
Unlike HMO plans, which require you to select a primary dentist and see only in-network providers, PPOs allow you to choose your dentist. In addition, you can usually visit any dental professional you desire within the PPO network, and you don’t need a referral to see a specialist.
Although you have more choice and power to choose a dentist than with an HMO, PPOs tend to have higher monthly premiums than DHMOs. However, they can save you money in the long run because they are designed to help you avoid paying more than you have to for dental care.
Like a DMO, most PPOs have a list of preferred providers contracted with the insurance provider for lower fees than non-preferred dentists. The PPO network is usually a large group of licensed professionals, and you can find out which ones are in it by looking at your plan’s provider directory.
Most PPOs pay for services performed by dentists not in the network based on an industry concept known as “usual, customary, and reasonable” (UCR) fee limits. But, it is essential to note that there is wide variation in how these fee limits are set. A particular provider or region negotiates some UCR limits, while others are determined by the plan administrator and not always transparent to the public.