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Dental HMO

A dental HMO is a health maintenance organization that focuses on dental issues.

Dental HMO

A dental HMO (health maintenance organization) has the same characteristics as a medical HMO. Under a dental HMO plan, the insured member incurs lower dental costs by using dentists that are part of the HMO network. The member selects a primary care dentist from a provider list and goes to that dentist for preventative care and most treatments. The insured must go to the primary care dentist and get a referral before seeing an in-network specialist for services to be covered. HMO participants do not receive insurance coverage for services rendered by a nonHMO network dental care provider. Although dental HMOs typically cost less than a PPO (preferred provider organization), they are not for everyone. Consumers should carefully evaluate costs, coverage, advantages and disadvantages before enrolling in a dental HMO.

Dental HMO vs. PPO

Dental HMO and PPO plans are both managed care plans regulated by state law. According to the Academy of General Dentistry, these types of plans make dental care more affordable by limiting the amount that a dentist can charge for treatment. As a result, dentists participating in managed care plans may be more focused on cost management than the actual treatments, which could have an impact on the quality of care a patient receives. According to the Journal of the American Dental Association, some dentists find that not charging for preventative examinations and cleanings as requested by managed care plans compromises good dental hygiene and prevention of dental disease.

Although HMO and PPO plans are similar, they each have advantages and disadvantages. The main advantage of a dental HMO is that there are no deductibles like there are with a PPO. Additionally, the co-payments of HMOs are usually lower than those of PPOs. The main disadvantages of dental HMOs are the selection of dentists is limited and patients must use an in-network provider to receive coverage. With a PPO, the patient will have lower out-of-pocket expenses by using an in-network dentist but will have some insurance coverage when going to an out-of-network dentist.

Costs of Dental HMOs

Although dental HMO plans do not have deductibles, they have the same features as other dental care plans, which may include:

  • Monthly or annual premiums
  • Office visit co-payments
  • No fees for routine or preventive dental services
  • Initial enrollment fee
  • Annual dollar cap on benefits

Dental HMO plans typically cost less than other dental care plans; however, actual dental HMO costs vary depending upon the plan. Dental HMO plans are called capitation plans because dentists are paid on a per-person (per-head) basis rather than for the actual services rendered. A basic dental HMO plan will cost members approximately $6 to $20 a month. Some critics believe that the low cost of dental HMO plans is a trade-off for quality of service. They also argue that dental HMO plans limit a patients choices regarding treatment, and the way in which dentists are compensated gives dentists incentive to provide minimal dental care.

Dental HMO Coverage

Dental cleanings, x-rays and other preventative services are generally provided at no charge to the member as long as the frequency of the services meets the terms outlined by the dental HMO. Members are typically required to pay a portion of the costs associated with other basic and major procedures, such as dental crowns, dentures, fillings and bridgework. Orthodontia is generally covered as well. Prior to treatment, a dentist should explain which costs will be the patients responsibility, although the patient should also verify coverage amounts directly with the insurance company before receiving any expensive treatments. Members are not required to complete any claim forms after receiving care from their primary care dentist.

Enrolling in a Dental HMO

Dental HMO plans are typically only available to individuals and their families through an employer or union. According to the American Dental Association, dental plan coverage for individuals is not widely available because insurance companies would end up paying more on benefits than they would receive on premiums for the number of individual dental plans written. During enrollment, each covered family member selects a primary care dentist. Most plans allow the member to change the primary care dentist simply by calling the insurance company or employer. Members receive an ID card that is presented at the dentists office so the dentist knows the specifics of the plan. For a family with two dental plans, it is important to know which parents dental plan covers the children before seeking dental care.

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