Types of Dental Plans

A PPO plan is regular indemnity insurance combined with a network of dentists under contract to the insurance company to deliver specified services for set fees and according to the provisions of the contract.

Contracted dentists must usually accept the maximum allowable fee as dictated by the plan, but non-contracted dentists may have fees either higher or lower than the plan allowance.

Under a DHMO or capitation plan, contracted dentists are “pre-paid” a certain amount each month for each patient that has been designated or assigned to that dentist. Dentists must then provide certain contracted services at no-cost or reduced cost to those patients. The plan usually does not reimburse the dentist or patient for individual services and therefore patients must generally receive treatment at a contracted office in order to receive a benefit.

An indemnity dental plan is sometimes called “traditional” insurance. In this type of plan, an insurance company pays claims based on the procedures performed, usually as a percentage of the charges.  Generally an indemnity plan allows patients to choose their own dentists, but it may also be paired with a PPO.  Most plans have a maximum allowance for each procedure referred to as “UCR” or “usual, customary and reasonable” fees. 

Point of service options are arrangements in which patients with a managed care dental plan have the option of seeking treatment from an “out-of-network” provider.  The reimbursement to the patient is usually based on a low table of allowances; with significantly reduced benefits than if the patient had selected an “in network” provider.

Exclusive provider organization plans require that subscribers use only participating dentists if they want to be reimbursed by the plan.  These closed panel groups limit the subscriber’s choice of dentists and also can severely limit access to care.