Deciding between PPO or HMO Dental Plans

10 Questions to help you decide between PPO or HMO dental plans

After reading the advantages of PPO and HMO plans, it’s now time to make a decision. Here is a list of question to better help you decide if you should choose a PPO or HMO dental plan. Please answer each question with either a “yes” or “no“:

  1. Are you expecting your dental treatment to include lots of work? Basically much more than just a simple cleaning or maybe a filling or two here and there.
  2. Do you anticipate the need for crowns or root canals in the near future?
  3. You’re suffering from a toothache right now or have been as of recently?
  4. Do you suffer from jaw (TMJ) problems, chronic bad breath, food getting trapped between teeth, or other similar dental related problems?
  5. Has it been a long time since you’ve gone to the dentist?
  6. You don’t have significant amount of existing dental work in your mouth already?
  7. Do you have advanced gum disease which requires constant treatment and frequent deep cleanings?
  8. Do you still have your wisdom teeth and you suspect that they might have to be removed?
  9. You don’t have any missing teeth in your mouth?
  10. There aren’t that many dentists in your neighborhood? For instance you live in a small town with only a handful of dentists available to you.

Good candidate for PPO dental plans

If you  answered “yes” to most of the above questions then you probably should probably consider selecting a PPO dental plan.

Questions 1 through 5: Anticipating dental work

If you need any sort of major dental treatment, such as root canals, crowns, bridges, etc. then selecting a PPO dental plan is most likely the better route to go. This is a good time to note that you should be cautious if you’re planning on receiving treatment such as dental implants, braces or cosmetic work. These treatments are often times not covered by neither PPO or HMO plans. So while having a good dental insurance can definitely help reduce your costs, expect to have substantial copays regardless of whether you have a PPO or HMO dental plan!

Dental implant coverage through dental insurance

A portion of your dental implant treatment may be covered by your PPO plan. However, the majority of dental insurances are still not covering dental implants. Many have a pre-exclusion clause which means that if you lost the tooth before you obtained this particular insurance then it would not be a covered benefit. Don’t forget that insurances require X-rays to verify this so you can’t get fool them either!

But even if your insurance does pay a portion, dental implant treatment will still require substantial out-of-pocket fees. Still, having a PPO plan could benefit you and reduce your costs by covering extractions and other related work. Also keep in mind that because of insurance maximum annual coverage, dental insurance is only helpful if you require one or two dental implants. If you’re expecting to receive a mouth full of dental implants, then you can’t rely on insurance and must pay for treatment yourself.

Orthodontic treatment coverage through dental insurance

Orthodontic treatment is typically only a covered benefit for children and young adults. Braces usually has an age cut off and adult braces is rarely covered. In addition to that, clear-braces is almost never a covered benefit. If you’re an adult who is planning on receiving orthodontic work, then inquire into what the age cut off is.

However, it might still be better to select a PPO plan if you’re planning on receiving braces. Your orthodontic treatment may require removing some teeth, restoring your teeth and possibly advanced gum cleanings so it’s always better to have good coverage just in case.

Cosmetic dentistry coverage through dental insurance

Cosmetic dentistry is never a covered benefit regardless of whether you have a PPO or HMO dental plan. Basically, you are going to have to pay out-of-pocket for teeth whitening or veneer treatments. Still, having a good insurance can come in handy. For instance, your dentist may be able to justify one or two ceramic white crowns as medically necessary in place of a few veneers and throw them in the mix. However don’t expect too much, as you will be on the hook for the majority of cosmetic treatment expenses.

Question 6: Existing dental work

If you already have a lot of existing dental work, then you need to always carry good dental insurance. If you’ve had a ton of fillings, crowns, bridges, etc. then you already know that things can always go wrong with them. And when they do, you almost always end up needing thousands of dollars in new dental treatment. Keeping a good dental insurance handy helps reduce your panic levels the next time one of your crown develops an infection or breaks off!

Question 7: Gum disease

If you have advanced gum disease, known as periodontitis, then you know the importance of regular dental cleanings. If you’ve been advised to get a dental cleaning every 3 to 4 months, then your gums require extra attention. Keeping a good dental insurance that allows for a few dental cleanings each year and covers deep cleanings can come in quite handy in these circumstances.

Question 8: Wisdom teeth

If you’ve already removed your wisdom teeth then you don’t need to worry about this. Also, if you’ve been advised correctly that you can keep your wisdom teeth, then you still don’t have to worry about this one. However, if you’ve had problems with your wisdom teeth in the past, then keeping a good dental insurance plan will definitely come in handy, just in case. In fact, it’s best to consider removing your wisdom teeth while you still have coverage to avoid future problems.

Question 9: Replacing missing teeth

If you have teeth missing then you need to have good dental insurance. Obviously you may require implants, bridges or dentures to close these gaps or replace failing existing ones. However, people with missing teeth are also much more likely to develop new dental problems than those with a full set of teeth. Gaps between your teeth can contribute to teeth shifting, food trapping, cavities, etc. which creates additional problems. As a result, it’s always best to keep a good dental insurance handy for when the next problem decides to occur.

Questions 10: Access to a dentist

If you live in a large metropolitan area like Boston, New York or Los Angeles, then there’s probably about 1,000 dental offices within a mile of where you live. You should be able to find a good dentist regardless of whether you have a PPO or HMO dental plan. However, if you live in a small village or town, access to dentists may be limited. If there’s only a handful of dentists around you, it might not be a bad idea to do some research and find out which dental plans they accept. It’s probably better to select a PPO plan in most cases as an HMO could mean driving a long distance or ending up with a dentist that you might not end up liking very much.

Good candidate for HMO dental plan

If you answered “no” to most of the above questions then an HMO dental plan is probably good enough. After all, if you require just two basic cleanings a year then why pay extra for something you won’t use? Even if you end up having to cover a small copay for dental cleanings or a filling or two here and there, it still makes more sense to stick with an HMO dental plan in these circumstances.

Final thought on choosing a PPO or HMO dental plan

The decision of choosing a PPO or HMO dental plan ultimately hinges on many factors including on how much treatment you require, how many dentists accept HMO plans in your neighborhood, what experience you’ve had in the past and other variables.

A PPO dental plan usually wins out because it basically provides you with better overall coverage, which is typically worth the additional monthly premium. Also, since more dentists accept these PPO plans, you’re more likely to end up in a nicer office with a dentist that you might actually like!

What to do if your dentist accepts both the PPO and HMO plan?

If your dentist accepts both PPO and HMO plans, then plan on starting off with PPO coverage. This allows you to fix necessary dental problems while reducing your out-of-pocket expenses. Once you have completed major treatments and begun maintenance phase, then you can consider switching to an HMO plan.

Keep in mind that this might take a while, so don’t be in a rush to switch too early either. Consider talking to your dentist beforehand to see if he or she recommends switching insurance plans. If you’re considered a high risk level patient then it’s not advisable to downgrade your insurance plan at any point. Discuss this with your dentist to see if this transition is suitable for you or not.

NEXT >> Benefits of PPO dental insurance plans

Benefits of HMO dental Insurance plans

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