PPO or HMO? A Clear Guide to How Dental Plans Work

Nearly all dental insurance falls into one of two broad types: PPO (Preferred Provider Organization) and HMO, also labelled DHMO or DMO. A PPO lets you choose your dentist and pays a percentage of each covered service. An HMO assigns you to a primary dental office within a narrow network and pays that office a fixed amount each month, whatever care you do or do not receive. That difference in how dentists are paid shapes a great deal of your experience, and it is why many independent practices, Eclat Dental Studio among them, work with PPO plans but not dental HMOs.

How a PPO dental plan works

A PPO is built on a network of dentists who have agreed to a set fee schedule for covered procedures. You remain free to see any licensed dentist, but visiting an in-network office costs you less because that office has accepted the plan's negotiated rates. Most PPO plans include:

• A yearly deductible that you meet before the plan begins to pay
• A coverage percentage that varies by type of care, often near 100% for preventive exams and cleanings, around 80% for basic work such as fillings, and about 50% for major work like crowns and bridges
• An annual maximum, the most the plan will pay in a benefit year
• No referral requirement to see a specialist

Eclat is in-network with all major PPO dental plans. If you have PPO coverage, our front desk can confirm your benefits before your first visit to our Mountain View studio.

How a dental HMO works

A dental HMO follows a very different model. On enrolling, you select a primary dentist from a limited network. That office receives a set monthly payment for each patient assigned to it, known as capitation, whether you come in once that year or ten times. Many services carry fixed copays; specialist care usually needs a written referral from the primary dentist; and care received anywhere other than your assigned office is generally not covered, apart from emergencies.

HMOs can be appealing on price. Premiums are lower, there is usually no deductible, and often no annual maximum. What you give up is flexibility: you need to stay within the network, you cannot simply choose any dentist, and the office is paid the same way regardless of how much time or which materials your care requires.

Why many independent dentists work with PPOs

This is the part plan brochures seldom explain. Under a PPO, the dentist is paid for each service provided, albeit at a discounted contracted fee. Under capitation, the office receives the same monthly payment whether a patient needs one cleaning or three visits and a root canal. That arrangement can create pressure to keep appointments short, postpone treatment, or favour the least costly option, none of which sits comfortably with careful, individual dentistry.

For a practice that invests in quality materials, unhurried hygiene visits and digital imaging, PPO agreements generally make the economics workable in a way HMO agreements do not. That is the straightforward reason we are in-network with PPO plans and do not accept dental HMO plans. It is not a judgement on anyone who has one.

A note on Medi-Cal dental

Government dental coverage works differently again. We accept Health Plan of San Mateo (HPSM) Medi-Cal dental, so eligible members can be seen at our studio.

What if your employer only offers an HMO?

You still have choices. Some people keep their HMO for the assigned office and simply see a dentist of their choice as a self-pay patient. Others use the next open-enrolment period to move to a PPO if one is available, since even a modest PPO usually keeps your freedom to choose a dentist and to see a specialist without waiting for a referral. If you have an HMO and are unsure how to proceed, please call our office. We are glad to talk through your situation and help you weigh the options, even if that means pointing you back toward your plan's network.

For ideas on keeping care affordable when coverage is limited, see our article on saving on dental care without insurance.

Common questions about PPO and HMO plans

Will my PPO be accepted at Eclat?

We are in-network with all major PPO dental plans. We verify the details of your specific plan before your first appointment so you know your coverage in advance.

Is HMO dental coverage bad?

Not at all; it is simply a different model. HMOs can work well for people who mainly need preventive care and are comfortable with an assigned dentist. They tend to suit less well those who value continuity with a dentist they have chosen, or who expect restorative, cosmetic or specialist treatment.

Why do plans have an annual maximum?

Annual maximums date back to how dental benefits were first designed decades ago, and they have not kept up with the cost of modern materials and technology. As a result, larger treatment plans often involve some out-of-pocket cost on top of insurance.

Do I need a referral to see a specialist on a PPO?

No. A practical advantage of a PPO is that you can refer yourself to a specialist such as an endodontist, periodontist or oral surgeon. Your general dentist still coordinates your care, but you do not need the plan's permission to go ahead.

Can I move from an HMO to a PPO?

Usually only during your employer's open enrolment or after a qualifying life event. When comparing, look beyond the premium to the breadth of the network, the annual maximum, and which local dentists are genuinely in-network.

We are happy to help you read your plan

Insurance should not dictate the kind of dentistry you receive. If you would like help understanding your benefits booklet, comparing open-enrolment options, or seeing what a treatment plan would cost you personally, our team is glad to go through it with you. Answers to other common questions are on our FAQ and patient resources pages, or call Eclat Dental Studio at (650) 917-8348 and have your insurance card at hand.