What is HMO Dental Insurance? Plans, Cost, FAQs, & More

HMO dental plans can be a confusing topic.

Throw in the other options for dental coverage and your decision gets even tougher.  Luckily, Authority Dental is here to help you sort through ALL the details.

In this guide to DHMO insurance plans, we’ll answer:

  • How do dental HMO plans work?
  • How much do HMO dental plans cost?
  • Which procedures do DHMO plans cover?
  • Do HMO plans have deductibles, copays, or coinsurance?
  • What do I need to know about DHMO plans before buying?
  • How can I get the most out of HMO dental insurance?
  • Are there any alternatives to HMO plans for dental care?

Before we dive into the details though, let’s start with the fundamentals.

What is a Dental HMO Insurance Plan?

A dental “Health Maintenance Organization” plan is a type of managed-care insurance plan. Also called capitation or pre-paid dental plans, they work much like HMOs for general health.

DHMOs are generally the least expensive type of dental insurance.  As you might expect, they are also the most limited.

How DHMO Plans Work

Happy Mature Man Having Dental Check-up In Clinic

The first thing you need to know about HMO plans:

They always use a “closed panel” network.

You must choose a primary care dentist from a group of preselected dental providers.  The focus is preventative care, which may be free after premiums.

However, not everything about HMOs is always as lovely as the price tag.

Make sure that you are thorough in your inspection of any HMO plan you consider.  They are not right for everyone.

Let’s dive a little deeper into how HMO networks operate before the main pro’s and con’s.

Network

DHMO networks are the most restrictive of any dental insurance plan type.  In some cases, your options may be limited to one dental care provider.

That primary dentist would act as “gatekeeper” for all dental services.

Basically, all dental procedures require his or her approval to be eligible for coverage.  Work outside their ability or ability requires a referral.  Specialists are often affiliated with the DHMO as well.

You may have a selection of primary care denists to choose from.  However, switching between them may have stipulations.  It all depends on your plan.

There are two different models that HMOs follow and it is important to know which kind you are looking at.  It will certainly shape your experience.

More on that later; let’s put things in terms of the good and the bad.

Selling Points

There are two major selling points for HMOs.

And boy, are they good ones:

  • Cost.  If available near you, HMOs are generally the most affordable plans around.  Once premiums are paid, preventative services are commonly covered at no charge.  That means exams, basic cleanings, and X-Rays may all be free.
  • Simplicity.  With HMOs, dentists agree to predetermined rates.  This eliminates the claims process altogether.  Therefore, you always know what you are going to pay.  What is and what is not covered should also be very clear.

client discussing with an insurance agent a dental insurance.Secondarily, there are usually no waiting periods for basic or major procedures.  This is an advantage they have over “point of service” plans such as Indemnity or PPO insurance.

However, they may leave out common basic or major procedures altogether.  Again, know your coverage if you’re looking to take advantage of a no waiting period dental plan.

And never forget the drawbacks!

Drawbacks

Made as simple as possible:

There are two major negatives for DMO plans.

  • Limited coverage.  Few DMOs could be labeled “full coverage dental plans”. Your network is likely to exclude some basic and major procedures.  If included, expect copayments.  HMOs sometimes leave out emergencies and orthodontia as well.
  • Quality of service.  This type of dental plan is more prone to horror stories than any other.  Many HMO dental practices are overbooked and understaffed.  Not every HMO is guilty.  But you must do you due diligence.

In many cases, HMOs are only suited for those in need of preventative care.

We will provide a list of questions you need to ask about your HMO plan later on.

For now let’s get to the part you care about the most.

How the Money Works

The best thing about HMOs is the numbers.

Affordable premiums are a given.  But HMOs are relatively hassle-free on the financial side as well.  Fee schedules are usually very clear.  That way, you generally know exactly what you’re getting into.

Plus, you might not have to worry about deductibles or annual maximums.

But the question still remains:

How Much Does HMO Dental Insurance Cost?

Dentist treating cute blonde child in his surgery.HMO dental insurance averages $27/month or about for $325/year per subscriber.  Per enrollee, it breaks down to $14/month or about $170/year. (Figures from 2016 via NADP)

Subscribers refers to all paying members.  Enrollees refers to all covered members, including subscribers and their covered dependents.  And averages fluctuate greatly state to state.

The lowest dental insurance premiums found near you probably belong to an HMO plan.  However, just how low those premiums are will depend on your specific policy.

Copayment

HMOs generally have low copayments that are clearly outlined.

Most preventative procedures have very low or no copayment due at the time of procedure.  If there is one, it is usually $5-10.  Or it may be that a set number of these procedures are free and after that you have a higher copayment.

Covered procedures have copayment amounts based your plan’s table of allowances.  This amount may be due at the time of your procedure or included in a later bill, as determined by your plan.

Less Complications

Simplicity is one of the main benefits of HMO insurance for consumers.

HMOs streamline the claims process.  Usually, the consumer doesn’t have to deal with claims at all.  The pre-negotiated rates eliminate the need in most cases.

In addition, you’ll likely encounter less types of dental insurance fees.

According to the NADP, 93% of active DHMOs require a deductible of $25 or less per year.  Very often, there is no deductible.  Likewise, 93% of dental HMOs have no annual maximum.

This may not mean much to you now.  Just understand that other types of dental insurance have more financial complications.

HMOs make it easy on the consumer by taking on more of the administrative responsibility.

From The Dentist’s Side

Dental HMOs take on two different structures.Young blond hair female dentist standing in his office and looking at camera.

Scenario 1:  Independent dental care providers contract with the insurance company. These dentists and other professionals receive a fixed amount based on the number of patients enrolled.

Scenario 2:  The insurance company employs dental care professionals. These providers agree to offer lower service fees to enrolled members, in exchange for consistent business.

In both scenarios, dental care providers get paid a more-or-less fixed rate.  This creates unique dynamics that don’t exist in point of service plans.

On the positive side, it reduces financial pressure on the dentist. They can worry more about providing excellent care and less about selling their most profitable procedures.  The assurance of income can increase both transparency and quality of service.

It can also encourage dentists to recommend proper diet and dental hygiene. This can lower the number of patients who need treatment without lowering the dentist’s pay.

(Non-HMO dentists make more money if they let their patient’s teeth rot.  After all, major procedures cost much more than preventative ones.)

Ideally, DHMOs lead to more honest dentist-patient relationships.

But it doesn’t always work out that way.

Every hand in the “cookie jar” wants to pull out more than crumbs.  Both the management company (DHMO provider) and dentists need to make their cut.

In an effort to turn a profit, the HMO insurance provider may overburden their dentists.  Or, they may limit or omit coverage on  popular procedures.

This is not always the case, but it can lead to several bad outcomes.

Don’t Get Taken Advantage Of

DHMO horror stories come in many forms.dental school students

First come the ones about terrible service.

We’ve already mentioned the potential for over scheduling.  But some plans even enforce time limits on patient visits.  Plus, there are a myriad of administrative complains that come up as well.

Furthermore, the best dentists in your area aren’t part of  dirt cheap HMOs.

These things can be chalked up to “you get what you pay for” though.  After all, less than $20 a month for free cleanings is a great deal.

The real problems go beyond poor service.

Some HMOs (or the dentists in them) seem prone to “bait and switch” tactics.

First, your dentist might try to sell you procedures that are outside of your plan’s coverage.  With no pre-negotiated rate, you may end up overpaying.

Think of it this way:

A dentist may agree to offer exams and cleanings for a super low rate in exchange for the chance to sell full-price root canals and extractions.

Second, your primary dentist acts as a “gatekeeper” for all your dental care.  They decide which procedures are appropriate.  This means you need a referral from them to see a specialist.

Your plan may only cover specialists within the HMO’s network.  Again, these specialists may be limited by the policy.  The coverage could be low.  Or the specialists may not be high quality.

To read about some of the negative experiences others have had with DHMOs, check out this forum discussion.  And again, take special care to ask around about any HMO you are considering.

At the end of the day, similar conflicts of interest exist in all dental insurance plans. But knowing what you’re getting into can ultimately make a huge difference in your level of satisfaction.

Educated consumers are much less likely to feel taken advantage of.

But still, learn everything there is to know about and the question remains:

Should I Choose a Dental HMO?

This can be a tough decision for some.

But it won’t be for most.  The strengths and weaknesses of HMOs fit best for certain groups of people.

Best for Who?

Monthly HMO premiums are about half the cost of other types of dental insurance.  That makes HMOs appealing to most people.

A high quality HMO is usually the best choice for families.Dentist curing a child patient in the dental office in a pleasant environment.

Saving 50% on a 4 or 5 member policy can make all the difference.  The focus on preventive care also works great for families.  Plus, more than half of DHMOs cover orthodontics without a maximum.

HMOs are great for individuals who only need preventive care.

If you have relatively good dental health, HMO dental insurance will bring you the lowest monthly and out-of-pocket costs.  Most plans cover exams and cleanings once or twice a year at no charge.  X-rays may be included as well.

A DHMO may also be the best option if you need major work soon.

Most PPO and indemnity insurance plans have waiting periods for major procedures.  They also tend to have annual maximums.  DHMOs have neither.  You usually get unlimited coverage on all covered procedures.

HMOs are the most popular type of dental insurance today.  It’s pretty easy to see why.  They fulfill the main purpose of dental insurance the best.

However, there are a few good reasons why a DHMO plan might not be the best choice for you.

Who Should Avoid

Other choices may be better under several circumstances.  It could be about the HMOs near you or your specific needs.

Those who need ongoing dental care may save more with other plans.

PPO and indemnity plans tend to cover major procedures at higher percentages.  Some HMOs may not cover the treatment you need at all.  Depending on your needs, a discount dental plan may even be the best option.

HMOs may be a poor choice for those intending to move soon.

HMOs have the most restricted networks of any dental plan type.  They offer no out-of-network coverage.  Plus, all service must have a referral from your primary care dentist.  This makes HMOs a bad choice or travellers as well.

Those with special needs may have difficulty with dental HMOs.

Those with limited mobility may find it difficult to find a plan that suits them. You may have to do quite a bit of traveling if the HMO network doesn’t include any handicapped-friendly offices near you.

HMOs should be avoided when options near you offer poor service.

Again, the horror stories.  It is extremely important you seek out reviews of the HMOs near you.  We advise you to go beyond online reviews and talk to the people that left them.  You also want to talk to the dentists themselves.

To a great extent, your choice is dictated by the options in your location.  Just don’t neglect your needs.

We’ve mentioned them some already, but let’s touch on the other dental coverage options available.  You can’t make a truly educated decision before you see how HMO plans stack up.

Alternatives to HMO Dental Insurance Plans

Cheap dental care sounds great. Smiling senior woman with new dental implants sitting in the dental office and looking at the mirror

You know HMO insurance can give you that.  But you also understand that it has weaknesses.  Otherwise, HMOs would be the only type of coverage out there.

Let’s start with the other type of managed care plan:

PPO

PPOs are another type of managed care plan with a larger provider network.

Like HMOs, there is no claim filing.  In contrast, PPOs do not require a primary dentist or referrals.  They offer coverage outside the network as well.  Some also offer higher benefits for basic and major procedures.

However, PPO premiums cost about twice as much.  Most PPOs have annual maximums and waiting periods to navigate.  They are also slightly less likely to offer orthodontic coverage.

Indemnity

Indemnity insurance is the name of traditional insurance, without a dental provider network.

Indemnity patients usually have to deal with the claims filing process themselves.  Doing so gives them the freedom to pay for a dentist they choose.  Indemnity insurance also covers basic and major services at higher rates.

Indemnity insurance premiums are even higher than those of PPOs.  Annual maximums and waiting periods are likely, unless you’re willing to pay extra.  They are the least likely to cover orthodontia.

Savings

Dental discount plans are an alternative to dental insurance coverage.

You never have to deal with a claims filing.  You simply pay a membership fee and receive discounts on the treatments listed in your plan.  You have the choice of providers in that plan’s network.

You can select a plan that fits the treatments you or your family need.  And you’ll never have to deal with the complications of insurance.  Depending on the plan you select, you may save 10-60% on out of pocket dental costs.

Take Aways on Dental HMOs

Congratulations on making it to the end.

You’re one step closer to choosing the right dental insurance for you.  But we’ve thrown a lot of information at you.  So let us review.

The good:

  • HMOs are the cheapest type of dental insurance for preventive care.
  • Because HMOs are a type of managed care, claims are not an issue.
  • HMOs are less complicated than other insurance types for patients.
  • HMOs are the most affordable choice for the vast majority of people.

The bad

  • HMOs make you choose a primary dentist, who acts as gatekeeper.
  • HMOs provide the fewest provider options of all dental plans types.
  • HMOs are more likely than other coverage to offer a poor service.
  • HMOs should be avoided for those in certain, unique circumstances.

While the cost-factor is compelling, there are obviously a lot of moving parts.  You probably want to do some additional research before making a decision.

Our expanded comparison of the different dental plan types is a great place to start.

If you have any specific comments or questions about dental HMOs, please leave them below!  And please, like and share this post.  A lot of time and effort went into making it the best resource for HMO dental insurance online.

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