PPO Dental Insurance Plans for Individuals: FAQ, Cost & Alternatives

If you’re looking into dental PPO plans, you’ve come to the right place.

Shopping for dental coverage isn’t easy.  There are a lot of options out there.  And while choice is great, it can also lead to an overwhelming number of questions.

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

  • How do dental PPO plans work?
  • What can I expect to pay for a PPO plan?
  • What part of my dental costs will insurance pay?
  • Do PPO plans have deductibles, copays, or coinsurance?
  • What should I consider when shopping DPPO plans?
  • How can I get the most out of my PPO dental plan?
  • What are the alternatives to dental PPO plans?

But first, let’s start with the most basic question of all:

What is a PPO Dental Insurance Plan?

A dental “Preferred Provider Organization” (DPPO) plan is a type of managed-care insurance plan.  They work similar to PPOs for general health care, with some differences.

PPOs generally toe the line between HMO and indemnity plans:

Monthly premiums are higher than HMOs but you get more coverage; premiums are lower than indemnity plans but you have less freedom.

How DPPO Plans Work

PPO plans mix the “closed panel” and “open panel” models.

Closed panel plans offer discounts through a network of preferred dental providers.  Open panel plans offer the freedom to go to any dentist.

With a PPO, you get a preferred provider network and the ability to choose.

Let’s take a look at how that works.

Network

Technically, PPOs are closed panel plans.  In fact, they are the original type.

But we like to call DPPOs “semi-open” panel.

Similar to HMOs, the insurance company negotiates reduced rates with a group of dentists.  Such networks may also include prosthodontists, periodontists, and even cosmetic surgeons.

In contrast to DHMOs, DPPOs generally have stronger network options.  Unlike HMOs, you probably won’t have to choose a primary dentist.  (If so, your plan is a PPO subtype known as an EPO.)

You can usually see any dental professional in the network, without referral.  Also, networks are usually much bigger.

But like an Indemnity plan, you can also go outside of the network and then apply for reimbursement.  However, you would not receive the same discounts you would if you were to stay in-network.  You also have to go through a claims process.

Therefore, DPPO customers have options that others don’t.

This leads us nicely to the strengths:

Selling Points

Individual plans vary.

But as a whole, PPO plans have two main advantages.

  • Flexibility.  DPPOs offer more options than other dental plan types.  PPOs offer discounts through preferred provider networks.  But they also cover out-of-network procedures with reduced benefits.
  • Simplicity.  The main objective of managed care dental plans is to simplify claims processing.  As long as you choose an in-network provider, PPOs save you from this hassle.  This is the original aim of managed care.

Compare individual PPO plans to make sure you find the benefits that fit you.

Remember, PPOs play the middle between HMO and Indemnity dental plans.  In many areas, you can find PPO plans that lean either way.

So make sure to identify your needs before you begin to shop.  Once you do, you may realize that there are better options for you (and your family).  That’s because other plan types lean harder on their strengths while PPO plans try to limit weaknesses.

This leads us directly to the weaknesses of DPPOs.

Drawbacks

Just like the positives:

It makes the most sense to focus on two main negatives.

  • Cost.  Monthly premiums for PPOs are generally twice as expensive as those for HMOs.  You may also find better coverage on preventive services with HMOs.  Indemnity plans may provide better coverage on major procedures..
  • Complications.  This may seem to contradict the second strength from above.  However, the complications come from PPO plan details, not the claims process.  The variety of options and configurations can be very confusing.

You pay a higher monthly fee (than HMOs) for the ability to go to the dentist of your choice.  On the other hand, your coverage levels and freedom of choice may be lower than competing Indemnity plans.

PPO plans come in a variety of configurations.  This includes different network sizes, coverage levels, and other stipulations.  For instance, many PPO plans make you wait an entire year to receive benefits on major procedures.

It is crucial that you understand your plan to the last detail.  This is the only way to make sure you maximize your overall savings.

Speaking of which, we know you want to know…

How the Money Works

This is probably why you came here.

You know that dental insurance may help you save money on total dental expenses.  But when it comes to PPOs, it is especially important to navigate your plan correctly.  If you want to save the most, you need to understand how the money works.

Managed care reduces hassles, but there are still a variety of considerations you need to make.  This includes payment and related issues.

But first, let’s answer the first question on your mind.

How Much Does PPO Dental Insurance Cost?

PPO dental insurance averages $48/month or about $580/year per subscriber.  Per enrollee, it breaks down to $24.50/month or about $294/year. (Figures from 2015 via NADP)

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

These totals are about twice as high as HMO premiums.  However, monthly payment amounts don’t tell the whole story.

Copayment

Managed care dental insurance emphasizes preventive care.

Preventive or diagnostic services are often offered at no additional charge (less your deductible).

PPOs are no different.  Yet, you can expect stronger coverage on basic and major procedures than you could get through an HMO.  These coverage levels often come with their own set of rules.

Unfortunately, such rules around payment aren’t simple.

DPPOs usually require deductibles and copayments.

There are a lot of moving parts when it comes to calculating your final out-of-pocket costs.

Unfortunately, the complications aren’t limited to the financial side of things.

Other Stipulations

The importance of understanding your benefits cannot be overstated.

Dental insurance plans are created to make money.  As such, there is a lot of “give and take” between plans.  So you may find major differences amongst PPO plans in your area.

At the very least, there are a few details you want to look into.

For example, many people begin looking for dental insurance because they know they need work done.

If that’s you, annual maximums and waiting periods are major concerns.  Both of these stipulations help insurance companies protect their profits.  Expect to pay extra for any dental insurance without an annual maximum or PPOs without waiting periods.

Beyond these restrictions, orthodontia benefits may be important to you.  About half of all PPO plans cover braces and/or other corrective treatments.  Dental insurance that covers cosmetic procedures is few and far between, but it does exist.

These features play a role in premium prices.  They may also affect coverage levels.

In this way, higher price may point toward the strongest coverage.  However, you can’t assume that higher priced plans are better—or offer the benefits you need.

Remember, insurance companies spend a lot of money on marketing and lawyers.  On the front, plans sound great.  On the back, plans give the insurance company as many ways out as possible.  Always keep this in mind.

One of the advantages of managed care, however, is the transparency that a preferred provider network can provide.

In-Network vs. Out-of-Network Costs

DPPO insurance plans are made to encourage network usage.

If you choose an out-of-network provider, expect to pay more.

Your plan’s preferred providers agree to reduced rates for increased business.  Don’t expect fee-for-service dentists to accept the same fee.  Therefore, you’ll almost alway pay more when going out-of-network.

In addition, many plans use an alternate compensation model for out-of-network coverage.  MAC plan or low-percentile UCR fee schedules are common.  This often puts out-of-network coverage levels even lower than in-network rates.

What does that mean?

Let’s say the average root canal costs $1000 near you.

Your plan may negotiate a rate of $800 with its network.  They classify it as a basic (category II) procedure, of which they cover 80%.  They pay $640.  You pay the remaining $160.

For out of network coverage, your plan sets a MAC fee of $700.  Root canals are still a major procedure, at 80%.  They pay (at most) $560 to any out-of-network dentist.  You’re left with the difference.  If you find a dentist cheaper than $700, they will pay 80% of that price.

Bottomline?

PPO plans are designed to save you the most money through their network.  You are almost guaranteed to pay more if you go outside of it.

However, there may be times when this is appropriate.

So let’s take a look from another angle.

From the Dentist’s Side

Many dentists today are members of preferred provider organizations.

After all, accepting popular insurance leads to more patients.  This helps their bottom line.  However, running a dental practice is expensive.  Many dentists feel that they already charge the lowest prices they can.

Thus, it is helpful to break dental professionals’ down into two perspectives.

First, let’s talk about the one you’re most likely to see.

Preferred Providers

Dentists join networks to get more business.

And in many cases, dental professionals have several choices.  Generally, PPOs pay more than HMOs on a per-patient basis.  But even PPOs offer different packages for dentists.

Afterall, dental insurance companies want good dentists on their networks.

Good dentists want to be paid more.  This is why you can expect better service from a DPPO than an DHMO.  Plus, the PPO structure still allows for a bit of competition within the network.

This is even more true now that more plans are embracing network sharing.  With network sharing, dentists gain access to more patients and patients gain access to more dentists.  And within this market, dentists are competing at reduced rates.

You save money.  But you don’t have to deal with time limitations or other issues that arise within HMO networks.

Still PPOs and HMOs have the same original intent:

Streamlining the claims process.

Any dentist in your preferred provider network will handle your claims.  The pre-determined rates make it easy to know exactly how much you are going to pay.  Often, this peace of mind is the most important thing for dental consumers.

You probably won’t get such service if you leave the network.

FFS Dental Professionals

Fee-for-service is the term for dental work without a network.

FFS dentists probably aren’t going to agree to the reduced rates of your in-network providers.  If they did, your network wouldn’t have much value anyway.

While you are almost guaranteed to pay more, you may receive better service.

After all, they don’t have to offer discounts to get customers.  This may indicate superior service.

This is one reason PPO plans offer out-of-network coverage.  They understand that you may have more faith in someone outside the list.  Or maybe you need major work and would feel more comfortable with a well-reputed specialist.  It could be that one member of the plan wants to stick with an old dentist.

There are a variety of reasons to shop fee-for-service dentistry.  You might even find a rare deal that beats in-network benefits.

Just keep in mind that price isn’t the only reason to stick to your network.

Never underestimate the dental insurance claims process.  It is a major hassle for untrained consumers.  Not only will you be responsible for the paperwork, but you’ll also have to pay your entire detail bill up front and wait for reimbursement.

If you leave your network, do you best to get pre approved and pre determined.

You might even be able to negotiate with the dentist’s office to help you file your claim.

That’s good to know.  But let’s move on to the most important question.

Should I Choose a Dental PPO?

This is why you are reading this post:

To find an answer to that question.

It can get a little tricky.  But we’ll do our best to simplify.

Best For Who?

PPOs are best for individuals that value balance and flexibility.  Unsurprisingly, they also work well for large groups with a diverse range of needs.

Dental PPO options are especially attractive to employers.

Most employer-provided dental insurance today comes from a PPO plan.  Dental insurance is a great way to reduce turnover.  And many DPPOs are built to cater to companies and other organizations, large and small.

Many PPO options do a great job providing reasonable coverage for employees.

The vast majority of active dental insurance accounts come from organizations.  If your employer offers dental benefits, use them.  Employers save by buying in bulk.  There is a good chance that you can get a great value.

DPPOs are a good choice for those with location instability.

PPOs are often the best choice for those going through major transitions, especially families.  Whether you’re planning on moving soon or have recently, a PPO plan will provide added flexibility but still help you save money.

Dental PPO plans allow family members to see different dentists.

Many families choose dental PPO plans for this specific purpose.  Often, the kids see in-network providers, where preventive care is very low cost.  Then, the parents stay with their long-term, fee-for-service dentist or specialist,

PPOs are the most diverse dental plan type, catering to different dental needs.  The managed care model helps to simplify claims.  But plans still facilitate fee-for-service procedures.

However, savvy shoppers can often find a better choice.

Who Should Avoid?

Dental PPOs play the middle.  If you identify your needs more specifically, you can probably find a better choice.

Settled families can usually find more affordable dental benefits.

A quality HMO will save the average family more per year than any other plan type.  If you have children, with no intention of moving, look into DHMOs near you.  DHMO premiums are often half the cost of DPPO premiums.

Those who need major dental work soon may need to shop around.

Like indemnity plans, many PPOs have a waiting period on basic and major dental procedures.  This can range from 6 months to 2 years.  Or, there may be no waiting period.  Identify your needs and shop accordingly.

Avoid any closed panel plan with a poor network reputation.

Any managed care plan is only as good as the dentists in its network.  It’s always best to question other customers before joining any network plan.  PPOs are less prone to “horror stories” than HMOs.  Still, do your due diligence.

Those who need ongoing major dental care should explore other options.

A strong PPO plan may be a start.  But if you have extensive dental needs, it won’t be enough.  Don’t forget that most PPOs plans have an annual maximum of $2000 per year, or less.  For some reading this, that is insignificant.

It’s important to understand that dental insurance plans aren’t magical discount pills.  And dental insurance marketing teams don’t always have your best interests in mind.

If you want to save the most money possible on dental care, you have to educate yourself.  The only way to make the right pick is to understand the difference in your plan options.

Like it or not, your dental care options go way beyond PPO insurance.

Alternatives to PPO Dental Insurance Plans

Despite all you have to learn, options are a good thing.

Different dental packages arise from customer demand.  This is why we think it is so important to identify the type of dental customer you are and shop accordingly.

Your choice can can save you $100s or $1,000s.

So make the right one.

Dental PPO Plan Sub-Types

PPO plans go by many names.  In fact, so do the other types of dental insurance.

But with PPOs it is slightly different.  There are a lot of different names for PPO plans.  These include EPO, MAC, ToA, hybrid, and whatever name the insurance company comes up with.

EPO plans are basically a PPO where you must choose a primary dentist.  MAC plans are PPOs with less out-of-network coverage.  Other names, like “table of allowance plans” and “hybrid dental plans”, are less defined.

(Don’t forget: Always READ YOUR PLAN and ask questions!)

HMO

HMO dental insurance  (a.k.a. capitation) is type of managed care with a true closed panel.

Like PPOs, HMOs cut out the claims process.  But they have stricter networks and almost always require a primary care dentist.  Preventive care may be free but some major procedures may be excluded completely.

Monthly HMO bills are half the price of PPOs.  Waiting periods and annual maximums are uncommon.  Braces are usually covered.  But you are at risk for terrible customer service (and maybe terrible quality of care).

Indemnity

Indemnity (a.k.a. traditional) dental insurance uses no provider network or claims management.

Indemnity patients pay up front and then apply for reimbursement.  Taking responsibility for the claims process gives them the freedom to select any dental care provider they want.  You might also receive higher coverage.

Indemnity premiums are the highest of any dental insurance type.  You might also encounter waiting periods and annual maximums.  And you are least likely to find indemnity plans that cover braces.

Savings

Dental discount plans are not insurance, but can have a similar (or greater) effect on your dental bills.

There is no claims process involved at all.  Your pay a monthly or yearly membership fee for discounted treatment from select providers.  You can choose from any dentist that is a part of the program.

You might hear them called referral plans, dental memberships, or a host of other names.  But as a whole, you can use dental savings plans to customize your care.  Single plans may help you save 10-60% on out-of-pocket costs.

Take Aways on Dental PPOs

Excellent work making it this far.

You’re one step closer to choosing the right dental care.  We know that was a major info dump.  So let’s take a moment to lock in those gains into your brain.

The good:

  • The right PPO may help you save $1000s on yearly dental expenses.
  • PPO network dentists handle the claims process for in-network care.
  • DPPO networks usually contain quality dentists competing for you.
  • Dental PPOs provide a high level of flexibility for those who need it.
  • PPOs offer the best options to employers who want to offer benefits.

The bad:

  • Dental PPOs have no real strengths because they play the middle.
  • DPPOs may be subject to waiting periods and annual maximums.
  • Most dental insurance patients can save more with other plan types.

Unless it comes from your employer, you can probably save more money with a different kind of plan.  PPOs certainly have their place.  But only you can decide whether that place is amongst your monthly bills.

If you’re still unsure, you might check out our full comparison of dental plans.

Have a specific comment or question about dental PPOs?  We’ve love to answer them below!  And please, like and share this post if you found it useful.  We’d love to help even more people save money on dental care!