PPO Dental Insurance

What is PPO Dental Insurance?

PPO stands for “preferred provider organization.” In a preferred provider organization, plan enrollees have the option of using an in-network dentist or an out-of-network dentist.  The most inexpensive care for a PPO plan enrollee would come from an in-network dentist. Another advantage of in-network dentists is that they are not allowed to perform “balanced billing.” Balanced is a practice where a dentist accepts the reimbursement rate from the insurance company but sends a separate bill to the patient for difference between the insurance reimbursement and the dentist’s normal charges.

A brand name preferred provider organization dental plan (also referred to as a DPPO or dental PPO) have large networks consisting of thousands of dentists. This scale provides plan enrollees with a broad inventory of local practices from which to choose, which increases your chances of using the dentist you want at a convenient location. HMO dental insurance, in comparison, has narrow restrictive dentist networks (for a more extensive comparison of PPO and HMO dental plans, see Dental PPO Plans versus Dental HMO Plans).One of the advantages of a plan’s dentist network is that the insurance company has negotiated lower costs for services than would be the case for an uninsured dental customer. An insurance plan may be able to negotiate rates that save 30 percent or more compared to standard dental rates for uninsured patients.

Negotiated prices have multiple benefits for a plan’s enrollees. First, many out-of-pocket costs on a dental plan are based on a percentage of the service’s total cost. Negotiated prices make the total cost lower and pass on savings when an out-of-pocket cost is based on the amount. Second, negotiated prices also benefit enrollees when they are in the deductible period where you pay 100 percent of a treatment (until the deductible is satisfied).

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PPO Dental Insurance Providers

There are dozens of insurance companies selling dental policies across the United States. Some are nationally known brands and others serve a regional a multi-state area or a single state. Interested to see what dental insurance providers offer plans in your area? Just visit our page for free dental insurance quotes. You can review plan options and compare rate quotes in a matter of seconds. If you prefer to just review insurance companies with PPOs regardless of whether they’re offered in your area, you can visit our list of dental insurance companies. This page details the companies with whom we do business, the types of plans they offer, and the number of states in which we have access to these plans.

Buying PPO Dental Insurance

While our introduction touched on PPO’s availability, provider networks, and rate discounts, there are more characteristics that account for the popularity of PPOs. To explain these issues, we need to review a few concepts: maximum benefits, deductibles, and dental insurance waiting periods.

Maximum Benefit

A maximum benefit is an annual cap on how much the PPO plan will pay for covered services during a one-year enrollment period.  Consumers are responsible for 100 percent of any service costs exceeding this limit during the plan year. While PPO plans (in contrast to HMOs) have maximum benefit limits, many PPOs have limits well above the typical dental expenses a consumer will experience during a year. Many PPO plans have a maximum benefit of $1,500 a year, with some as low as $500 annually. We have also seen maximum benefits as high as $5,000 (NCD Nationwide 5000 Plan and the Humana Extend 5000).

Deductibles

The deductible of a PPO dental plan is a dollar amount that the consumer pays at the beginning of a new plan year before the plan contributes to the costs of covered dental treatments. Deductibles vary by plan. Many PPO plans charge a modest deductible of $50 per enrollee per year. In some cases, there is a cap on the deductible for a family (e.g. a maximum combined deductible of $150 a year covering all enrolled family members).

PPO Dental Insurance - No Waiting Periods

A dental insurance waiting period is the time that must pass from the date your insurance plan become active to the date a specific benefit becomes eligible for coverage. Waiting periods vary by plan and are usually measured in months (e.g. 3 months, 6 months, 12 months). Many dental plans have waiting periods before expensive procedures are covered but some PPO plans have no waiting periods on their covered services. If you have a dental need that requires immediate care, make certain that care does not have a waiting period. For more information on coverage delays and examples of plans with no waiting periods, see our article on dental insurance no waiting period.

DentalInsurance.com’s dedicated plan pages include will inform you about any waiting period restrictions for a specific plan. PPO plans without waiting periods are sometimes called “immediate coverage dental plans” or “no waiting period dental plans.” To see the specific dental services covered by a PPO dental plan and whether any of them have a waiting period, compare PPO plans in your area with our price tool and then click on the More Details arrow on any plan that interests you. If you’d like more specifics on the plan, you can click the Full Plan Information button within the More Details section.

A Few More Key Insurance Terms

When you buy a plan on your own, it is considered private dental insurance. This distinguishes the policy from group insurance, which is obtained by companies, associations, and unions. If you have only yourself covered by your plan, it is individual dental insurance. If you have your spouse and/or children covered, then the policy is a form of family dental insurance.

Benefits and Trade-Offs

Below are some brief issues to consider when shopping for a PPO dental insurance plan. Like all dental plans, PPOs have both advantages and disadvantages.

Benefits:

• Consumers save you money through negotiated prices with dentists
• You still benefit from negotiated prices even if they exceed the plan’s yearly maximum benefit
• Large dentist networks that increase your chances of using the dentist you want
• A network is more than dentists; it’s also oral surgeons, periodontists, orthodontists and more
• Some networks have over 100,000 participating dentists
• Out-of-network dental care is an option
• In contrast, HMO plans where enrollees are restricted to  in-network dentists
• Claims are paid directly to dentists so you don’t have to wait for the insurance company to reimburse you
• You do not need to choose a primary care dentist
• You do not need referrals for specialty dentistry such as periodontic care

Trade-Offs:

• Out-of-network care comes with higher out-of-pocket costs
• Plans have an annual limit on how much the insurance company will pay for care
• Larger dentist networks and greater out-of-network care flexibility makes PPO premiums more expensive than HMO premiums

PPO Dental Network: The Size Advantage

PPO dental insurance is the most popular type of dental coverage in the market for private (i.e., non-business) dental insurance. The average dentist who accepts PPO coverage belongs to 26.5 different networks, according to statistics from the National Association of Dental Plans. PPO networks can have tens of thousands of participating dentists across the nation, with some of the largest networks exceeding 100,000 dentists.

If you want to see a dentist who is not part of your PPO plan ’s network, some PPO plans will pay based on an industry concept known as “usual, customary and reasonable fees” (UCR). Most out-of-network benefits, though, are paid by PPOs based on MAC fees (the maximum allowable charge for the plan). If MAC fees are used, you may have to pay the difference between the MAC and what your out-of-network dentist charges for the work.

PPO Dental Insurance Near You

If the above information on PPO dental plans has made you want to enroll in one, it is likely that one or more are available in your area. Just visit our page for dental insurance quotes. Review plan benefits and compare monthly premiums in a matter of seconds.

State-Specific Examples of PPO Dental Insurance Plans

Below are examples of PPO plans offered by DentalInsurance.com in each state. For a full list of PPO plans offered in your region, visit our dental insurance quote page.

NOTE - Some of the below plans may not be available in all regions of the state for which it is listed.

Frequently Asked Questions

Are There Limitations or Restrictions on PPO Dental Insurance?

All PPO insurance plans have conditions regarding their benefits. These can apply to who can provide dental care (i.e. network considerations), when a benefit is available (waiting periods), and the limit on dental costs during a plan year (i.e. the maximum benefit). A plan’s Summary of Benefits or Plan Brochure summarizes these conditions.

Unlike HMO plans, a PPO dental plan does not require an enrollee to choose a primary care dentist and the plan may not require referrals or prior approvals.

How Quickly Can I Get PPO Dental Coverage and When Will It Become Active?

PPO dental insurance can be purchased an online application process. During the application process, the applicant is told how quickly the insurance will become active after the application is submitted and approved. This is known as the Effective Date and it is often a few weeks from the time of application.

How Can Dental PPO Insurance Save Money?

There are several ways PPO dental plans can save a consumer money. First, the plan may have negotiated rates on dental care that are lower than standard retail rates. Second, a PPO plan pays money toward covered care with the enrollee paying a copayment or coinsurance fee. Third, a PPO may waive out-of-pocket charges for preventive dental care (i.e. annual exams and teeth cleanings).

Are There any Additional Perks or Benefits to PPO Dental Insurance?

Some PPO plans bundle additional benefits (such as vision and hearing care) with their standard dental coverage.

Do All Dentists Accept PPO Coverage?

No but, because PPO dental insurance is the most common form of private dental insurance, PPO dental coverage acceptance is very high. However, just because a particular dentist accepts some PPO dental plans does not mean he or she accepts all PPO dental plans.

Are PPO Dental Plans Available in Every State?

Yes. There are PPO dental plans in every state as well as the District of Columbia (Washington D.C.).

Can Individuals Enroll in PPO Dental Plans Year-Round?

Yes. There is not a fixed annual enrollment period for privately purchased dental insurance. Consumers can apply for coverage throughout the year.

How Straightforward Is The Enrollment Process for PPO Dental Insurance Plans?

Most PPO dental plans have a simple online application form that can be completed in a few minutes. The form will ask for information such as a credit card number as well as full name, address, age, sex, and similar information for additional family enrollees if applicable.

Which Insurance Brands Offer PPO dental insurance?

Since more than 80 percent of privately sold dental plans are PPO, most of the big brands offer this kind of coverage. Among the widely known PPO brands are Anthem Blue Cross Blue Shield, Cigna, Delta Dental, Guardian Direct, Humana, and MetLife.

Does Dental Insurance Come with Benefits Outside of Dental Care?

It depends on the dental plan. Some dental plans, such as Cigna’s Dental Vision Hearing 3500, combine dental benefits with vision coverage. Other plans may have special discounts available to members using their insurance.

Do I Need to Choose a Primary Care Dentist?

No. Primary care dentists are needed for HMO plans, not PPO. In a HMO plan, the primary care dentist not only provides regular dental care but approves or disapproves referral requests for other dental specialists.

What Are the Age Requirements for Getting a Quote?

Most insurance companies require an adult 18 years or older to be on a dental plan. Some insurance companies offer the option of child-only coverage where one or more children are covered by the plan but not the parents. This is less common so reach out to an insurance company prior to insurance application to verify child-only cover if that is what you need. For more information, see our article Dental Insurance for Kids.

What makes a PPO dental plan a good choice?

The main reasons for the insurance’s popularity are affordability, flexibility on the dentist you use, negotiated rates that save money off retail rates, no need for a referral to see a dental specialist, and no balance billing when an in-network dentist is used.  

Sources:

1. https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/about/annual-reports/ar_cdbp.pdf
2. https://www.deltadental.com/us/en/protect-my-smile/dental-insurance-101/ppo-dental-insurance.html
3. https://www.nidcr.nih.gov/research/oralhealthinamerica
4. https://www.aetnadentaloffers.com/lp-ppc/ado