Most PPO plans cover a percentage of dental service charges. For example, if your PPO covers 80% of a procedure, you are responsible for paying the remaining 20%. Preventative dental care, cleanings, check-ups, protective dental sealants, X-rays, and fluoride treatments are usually covered at 80-100%. Basic care, including root canal therapy, tooth extractions, and fillings are usually covered at 80%. Major care, such as crowns (caps), permanent bridgework, full dentures, partial dentures, and periodontal (gum) care, are often covered at 50%.

While 80% coverage in theory sounds great, it is important to understand that most of these plans have yearly maximums for dental care that are quite low in comparison to the cost of dental procedures. Additionally, most insurance companies have a deductible of $50 to $100, and only pay a specified percentage for each type of treatment. For instance, many insurance companies have a yearly maximum of just $1000. It is interesting and disappointing to note that when dental insurance companies emerged in the early 1970s, the yearly maximum was set at $1000. That amount, a $1000 maximum, has generally not increased over time. It remains the same today, despite the fact that the cost of dental care has nearly tripled since the time that the $1000 maximum was established. This makes current dental insurance seem more like a “rebate” on services rendered.

With HMO insurance, you select one provider that treats you directly and manages your care. You need a referral from your primary provider to see other specialists. HMO plans usually have no or low deductibles and lower co-pays than PPOs.

In recent years, HMOs have received a barrage of negative publicity. This mainly has occurred in the medical community for dubious “gag” clauses in contracts, bureaucratic snafus, and the limitation of appropriate care of patients by their physicians. While some HMO insurance plans may be adequate for practitioners in medical settings, they are more difficult to justify in the dental community. The main reason is that dental practice overhead amounts are generally higher in the average dental setting than the average medical practice. Additionally, the financial compensation to the dentist from most HMOs is very low considering that 65 to 70 cents of every dollar received at the average dental office is consumed by office overhead, including staff salaries, supplies, laboratory fees, rent, and other expenses.

The reduced fees stipulated by dental HMOs have dentists performing many dental treatments at a financial loss. A recent study by the American Dental Association found that the average dental HMO does not even adequately reimburse inexpensive preventative dental care. Consequently, a dental practice with a majority of patients having HMO insurance is often forced to see patients quickly—too quickly to develop the necessary rapport essential to the dentist-patient relationship. Consequently, in this practice, we do not accept dental HMO’s.