Preferred Provider Organization Dental Plans
Dental PPO plans allow subscribers to choose a dentist from either in-network or out-of-network options. They’re the most common option out of all dental plans available.
Covered Services
Dental PPOs divide their services into preventative, basic and major categories.
- Preventative services: Include two yearly cleanings/exams and diagnostic X-rays.
- Basic services: Include deep cleanings, fillings, treatment for gum disease and extractions.
- Major services: Include high-cost services, such as crowns, root canals, bridges, dentures and implants.
Coverage Limitations and Exclusions
PPO plans place limitations and exclusions on different types of coverage. Some are more restrictive than others, so it’s important to closely review a plan to understand its exact limitations.
Annual and Lifetime Maximums
Annual maximums are the capped amount that a plan pays per year. So if a plan has an annual maximum of $1,500, any additional costs are the subscriber’s responsibility.
Lifetime maximums apply to expensive dental services, such as dentures. Once the subscriber reaches their lifetime maximum, the plan won’t pay for that service anymore.
Waiting Periods
Waiting periods can vary between 6 months for basic services to a year for major services. Some plans have shorter waiting periods or no waiting periods at all. Additionally, some companies offer a waiting period waiver for people with recent comprehensive dental insurance on a different plan.
Treatment Exclusions
Plans may exclude a treatment category entirely or only cover the lowest-priced option to treat an issue. For example, a plan may exclude bridges or crowns or limit subscribers to a cheaper option.
Time Period Limits
Some plans may only cover a service every couple of years. For example, the plan may cover dental implants, but coverage may only apply for one implant every 5 years.
Pre-Existing Conditions
Some plans won’t cover dental issues that existed before coverage began. These include things such as existing crowns or missing and broken teeth.
Financial Pros and Cons of PPO Plans
PPO plans have the potential to save subscribers money, but they can also cost them money depending on how they use the plan. Here are the main financial pros and cons of PPO plans.
Pro: Potential Cost Savings
While the upfront costs are higher than some other options, it’s entirely possible to save a significant amount of money with a PPO plan if the subscriber uses it for more than just preventative care. In addition, subscribers can further maximize their savings by sticking to the plan’s in-network dentists.
Con: The Risk of Breaking Even or Losing Money
On the other hand, if the subscriber only uses their PPO plan for preventative care, they risk breaking even or losing money. For example, if the subscriber spends $360 on premiums every year and receives $300 worth of preventative care, they’d lose that extra $60.
PPO Plans vs. Indemnity Plans
Indemnity plans, also known as fee-for-service plans, are very similar to PPOs. Both usually feature a network of preferred providers. With a PPO, subscribers get the best coverage by using an in-network provider. With an indemnity plan, subscribers can get the same coverage regardless of network.
One notable difference is that balance billing occurs more frequently with an indemnity plan. Otherwise, much of the information above applies to indemnity plans.
Dental Health Maintenance Organizations
Dental HMO plans are structured very differently from PPO plans. While PPO plans are more common, HMO plans can be appealing because their low monthly costs range from $8 to $12 a month. The table below helps illustrate the main differences between HMO and PPO dental plans.
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Plan Feature or Benefit
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Dental PPO Plans
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Dental HMO Plans
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Annual maximum
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Yes
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No
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Coinsurance
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Yes (% of flat-rate)
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Yes (% of a dentist’s contracted rate)
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Copay
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Yes
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Yes (typically very low: $10, $20 or $50)
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Waiting Periods
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Yes
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No
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Deductibles
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Yes
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No
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In-network required
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No
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Yes
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Primary dentist required
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No
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Yes
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Generally speaking, HMOs are an option for seniors who are looking to keep dental costs low and don’t mind the restrictions of having to see a single primary dentist. However, dental HMOs aren’t available in every state, and policyholders can encounter long wait times to see a dentist. Those considering a dental HMO should review the plan documents thoroughly to decide if the coverage is a good fit for their needs.
Preventative-Only Plans
As the name suggests, these plans only cover preventative care. Subscribers typically receive two annual cleanings or exams and X-ray coverage. Paying for any additional services, such as fillings, is the subscriber’s responsibility. Preventative-only plans start at around $180 per year and can save people a few hundred dollars per year on essential dental care.
Discount Plans
A discount plan isn’t an insurance plan. Instead, it offers the subscriber access to a network of dentists who provide services at discounted rates. There are no waiting periods, copays or deductibles. Discount plans may also offer discounts for services not typically covered by PPO plans, such as teeth whitening and other cosmetic services. While the subscriber pays for all their dental care out of pocket, they can expect to see cost savings between 5% to 60%, depending on the plan.
What To Know When Choosing a Dental Insurance Plan
When choosing a dental insurance plan, seniors need to review the coverage and costs carefully to make sure the plan meets their needs. That way, they’re less likely to encounter unwelcome surprises, such as going to the dentist and finding out the care they need isn’t covered. When evaluating a dental insurance plan, seniors should carefully review the plan documents and look for the following information:
- Monthly or annual premiums
- Deductibles and co-insurance
- Coverage and exclusions
- Waiting periods
- Age limits
- Exclusions (for treatments or pre-existing conditions)
- Annual and/or lifetime maximums
- Dentist options and availability
- Senior discounts (if applicable)
FAQs
Will Medicare or Medicaid cover dental costs?
Medicare doesn’t cover dental costs. However, limited exceptions may exist for emergency dental surgery in a hospital setting. Additionally, some Medicare Advantage plans may include dental options.
Medicaid doesn’t require that states provide dental coverage for adults. Usually, Medicaid programs won’t cover anything other than emergency dental care. Check your state’s online resources to see if Medicaid can help with your dental care.
Does the VA provide dental coverage for veterans?
Yes, the Veterans Administration provides dental care for veterans. Consult your local VA chapter or its website to learn how to qualify for dental benefits through the VA.
