What Is a Dental DHMO Plan and How Does It Work?
Demystify Dental DHMO plans: understand their unique model for managed dental care and coverage.
Dental Health Maintenance Organization (DHMO) plans offer a structured approach to dental care coverage. This managed care dental insurance provides access to a network of dental providers for a predictable cost. DHMO plans facilitate regular dental maintenance and treatment through a pre-selected network.
Defining Dental DHMO Plans
A Dental DHMO plan operates as a managed care dental benefit program. This model is based on a prepaid system, where members choose a primary care dentist (PCD) from the plan’s network. The plan pays the dental office a fixed monthly fee, known as capitation, for each member assigned to that office, irrespective of whether the member receives services during that month.
This capitation payment provides the dental practice with a consistent revenue stream for managing the oral health of its assigned patients. In return, the dental office agrees to provide a range of covered services to these members at no additional cost or for a specified co-payment, as the financial incentive for the dental practice is tied to patient enrollment rather than individual services.
The DHMO Provider Network
Within a Dental DHMO plan, members must select a primary care dentist (PCD) from the plan’s network. This chosen PCD serves as the central point for all dental care needs, including routine examinations, cleanings, and any necessary restorative treatments. The PCD is responsible for coordinating the member’s dental health, acting as a gatekeeper for specialized services.
Should a member require specialized dental care, such as orthodontics or oral surgery, a referral from the PCD is necessary. This referral process ensures that the member sees a specialist who is also within the DHMO network. Services received from dental providers outside of the plan’s network are not covered.
Understanding DHMO Cost Structures
The financial framework of a Dental DHMO plan involves regular premium payments. These monthly premiums are lower compared to other types of dental insurance plans.
In addition to premiums, members pay fixed fees, known as co-payments, at the time of service for specific procedures. DHMO plans do not have deductibles, which are amounts members must pay before the plan begins to cover costs. Furthermore, these plans do not have annual maximums, meaning there is no cap on the total amount the plan will pay for covered services in a year.
Common Dental Services Under a DHMO Plan
Dental DHMO plans cover a broad spectrum of dental services. Preventive care includes routine cleanings, comprehensive examinations, and X-rays. These services have minimal or no co-payment.
Beyond preventive measures, DHMO plans also cover basic restorative care, such as fillings and extractions. More complex procedures, often referred to as major services, are included. These encompass treatments like root canals, crowns, bridges, and dentures. For each of these covered services, a specific co-payment applies.