What Is a DPPO Plan and How Does It Work?
Demystify DPPO dental plans. Learn how these flexible insurance options work, manage costs, and access the dental care you need effectively.
A Dental Preferred Provider Organization (DPPO) plan is a common type of dental insurance that helps manage dental care costs. It balances cost savings with the ability to choose your dental professional. DPPO plans cover a range of services, from preventive care to more involved procedures, making dental health more accessible and affordable. Approximately 89% of commercial dental policies are DPPOs.
Understanding DPPO Plan Structure
A DPPO plan uses a network of dental professionals who have agreements with the insurance provider. These “preferred providers” offer services at predetermined, discounted rates to plan members. Choosing an in-network dentist results in lower out-of-pocket costs due to these negotiated fees.
Members can select any licensed dentist for their care. While there are financial incentives to use in-network dentists, members are not restricted to them. They can choose an “out-of-network” dentist, who does not have a direct contract with the insurance company.
Using an out-of-network dentist results in higher costs. This is because non-network providers have not agreed to discounted rates, and the plan covers a smaller percentage of charges. The plan encourages network use by offering more comprehensive coverage and lower expenses for in-network care.
In-network dentists handle claims submissions and administrative tasks for patients, simplifying billing and reducing paperwork. The network also undergoes credentialing and quality management programs, ensuring a consistent level of care.
Financial Aspects of a DPPO Plan
Members pay a regular premium to maintain coverage. This premium allows access to the plan’s benefits and network discounts.
A deductible is an out-of-pocket amount a member must pay for covered services before the plan contributes. Deductibles often range from $50 to $100 per individual. Preventive services, such as routine cleanings and exams, are typically covered at 100% and do not count towards the deductible.
After the deductible is met, coinsurance applies. Coinsurance is the percentage of service cost the member pays, with the plan covering the rest. For example, a plan might cover 80% for basic procedures and 50% for major procedures. These percentages vary based on whether the provider is in-network or out-of-network, with higher out-of-pocket costs for out-of-network care.
An annual maximum is the total dollar amount the plan will pay for covered services within a 12-month period. This maximum typically ranges from $1,000 to $2,000. Once reached, the member is responsible for 100% of additional dental costs until the next plan year. The annual maximum resets at the start of each benefit period.
Accessing Care with a DPPO Plan
Accessing care with a DPPO plan begins with selecting a dentist. Members can find in-network providers using online search tools or directories from their insurance carrier, often via their website or mobile app. These tools allow searching by location, specialty, or dentist’s name. While members can choose any licensed dentist, opting for an in-network provider results in lower costs due to pre-negotiated rates.
After choosing a dentist, scheduling an appointment is straightforward. In-network dentists handle claims submission to the insurance company on the patient’s behalf. This simplifies the administrative burden, as the dentist’s office manages billing and benefit coordination directly with the insurer.
For out-of-network services, the claims process differs. While some out-of-network offices submit claims, members may need to pay upfront and seek reimbursement from their insurance company. Reimbursement for out-of-network care is less than for in-network services, and the member pays the difference between the dentist’s charge and the plan’s payment.
For extensive or costly procedures like crowns, bridges, or oral surgery, request a pre-treatment estimate, also known as a pre-determination or pre-authorization. The dentist’s office submits a proposed treatment plan and documentation to the insurer. The insurer reviews details and provides an estimate of plan coverage and the member’s out-of-pocket responsibility. This helps members understand potential costs before treatment.