What Is a Dental PPO Plan?

A trip to the dentist can be costly, especially if you need additional work done to keep your teeth healthy. Dental insurance is designed to help cover the costs of dental procedures, which can be difficult to cover if you’re not prepared for them.

There are different types of dental insurance plans, including Preferred Provider Organizations (PPOs) and Health Maintenance Organizations (HMOs). A PPO often provides more flexibility because you can choose from a wider range of dentists.

An HMO might have lower costs, but you have fewer choices. You can also choose from discount plans, which isn’t insurance, but offer access to lower prices at participating dentists. There are also indemnity plans, which allow you to visit any dentist but require you to do more claims paperwork.

Here’s what you need to know about dental PPO plans.

Introduction to dental PPO plans

Dental PPO plans operate similarly to other types of insurance plans.¹ You pay a monthly premium that entitles you to receive coverage for a range of dental services. However, you normally have to pay a deductible and coinsurance.

• A deductible is the amount you pay out of pocket each year before your insurance kicks in and the company starts paying claims for services.
• Coinsurance is the percentage you pay as cost-sharing with the insurer.

For example, if you have a dental PPO plan with a $250 deductible and 20% coinsurance, the insurance company won’t start paying claims until you spend $250 on dental services. Then, when the insurance does kick in, you pay 20% of the cost. So, if you’ve met your deductible and you need a dental procedure that costs $1,000, you owe $200.

PPO plans allow you to choose dentists and other oral health specialists from within a network of preferred providers for a lower out-of-pocket cost. Dental PPO plans also allow you to see dentists outside of the preferred network, but you usually need to pay a higher coinsurance rate.

Pay attention to the annual maximum benefit, however. Once you reach that maximum, you’re on the hook for costs during the rest of the year.

Comparing dental PPO and other dental insurance plans

When deciding if a dental PPO plan is right for you, compare it to other types of dental options.^1,2

Dental PPO plans combine a higher degree of flexibility than HMO plans, and with a lower cost than a dental indemnity plan usually offers.

With an HMO, you often pay a lower cost for monthly premiums and copayments for services than you would with a PPO. However, you must use only the dentists and specialists in the HMO network. On top of that, you usually choose a primary dentist and go to them for all your care (unless they need to refer you to specialist).

A dental indemnity plan is a fee-for-service plan, meaning that your plan determines what’s a “usual, customary, or reasonable” (UCR) fee for the service you require. You’re then reimbursed at that rate for the services you receive. You can see any dentist, and you don’t have to worry about whether they’re in network. However, these plans often cost more than HMOs and PPOs. On top of that, you need to submit for reimbursement, bearing the entire cost upfront.

Another option is to use a dental discount plan. However, dental discount plans aren’t insurance. Instead, you pay a small fee for access to discounts at participating dentists. You pay the dentist directly.

Benefits of dental PPO plans

Dental PPO plans include provider choice and flexibility, with various options that can match your budget.³

• Provider choice: You can choose any dental provider you wish, even if they aren’t in the insurer’s network. However, you can save money by choosing a provider in the network. Insurers typically have a good number of in-network providers with a range of expertise to choose from. For instance, with the MetLife Dental PPO plan, members have access to an extensive network of PPO providers that can perform everything from a routine check-up to more complex procedures.
• Pricing flexibility: PPO plans typically offer several pricing levels, so you can choose one that fits your budget. Look at the deductible you can afford, and review the coinsurance and other costs.
• Preventive care coverage: You typically receive a certain level of preventive care services, like basic cleanings, included with PPO coverage.
• No referral requirements: You don’t usually need to get a referral from a primary dentist to see a specialist with a dental PPO plan. This is different from the requirements of an HMO.

Can Dental PPO plans offer cost savings for families and individuals? 

Dental PPO plans can potentially provide cost savings, whether you have a family or it’s just for yourself, by helping pay for part of the expenses associated with dental care that’s covered. Before deciding on a plan, make sure you understand whether your provider is in-network. With a PPO plan, you pay less out-of-pocket when your provider is in-network.

For example, MetLife’s Find a Dentist tool can help you search for dentists by location, specialty, and other criteria, so you can find a high-quality in-network dentist that meets your healthcare needs. You can also find information about licensing, languages spoken, and office hours.

The main benefit of dental insurance is that you don’t have to bear the entire cost of an expensive dental procedure on your own. For example, let’s say you have a procedure that costs $3,000. You have a deductible of $250 and a 20% coinsurance rate. If you haven’t paid anything toward your deductible yet, you’re responsible for the first $250, plus 20% of the remaining bill, or $550. Your total cost would be $800, rather than the entire $3,000.

Comparing dental PPO and HMO plans 

When deciding between a dental PPO or HMO, consider your various needs, including how much flexibility you want in provider choice.

An HMO might cost less, but you can’t go out-of-network and receive coverage. Additionally, you might have more limited care options, and you usually need a referral to see someone other than your primary dentist.

If you want to be able to see a specialist without a referral and have a wider choice of providers, a PPO might make more sense, even if the premiums are a little higher.

Understanding coverage: In-network vs. out-of-network

An in-network provider is someone who agrees to provide services to insurance members at a lower rate. The in-network provider has a contract with the insurance company and will charge a preferred rate for services.

An out-of-network dentist is someone who hasn’t negotiated those rates with an insurer. You can see an out-of-network provider when you have a dental PPO plan, but because they don’t have an agreement with your insurance company, it will likely cost you more money to see them.

Often, dental insurers require a higher coinsurance rate from you for out-of-network providers. For example, you might pay 20% coinsurance with an in-network provider, but pay 60% coinsurance for going out-of-network for dental care.

Verify that your provider is in-network before you set your appointment. Consider reviewing the providers in a dental insurance company’s network before purchasing a policy. This can save you money since you won’t be surprised with a higher bill for visiting someone out-of-network.

Enrolling in a dental PPO plan

Many employers offer dental PPO plans as part of open enrollment. If you get your dental insurance through your employer, understand when open enrollment is and use it as a time to review your coverage and options.

You can also get dental insurance on the Health Insurance Marketplace during open enrollment, but keep in mind that you have to enroll in a health insurance plan at the same time if you get a stand-alone policy. Some health insurance plans on the marketplace include dental insurance as part of their coverage.⁴

When you shop for a dental insurance plan, remember to compare different companies and what they offer on factors such as:

• Size of the network and how many providers are included
• Whether your preferred dentist is in the network
• Whether preventive services are included 100% in coverage
• If you expect to need additional dental procedures or care, and what’s covered

Once you have this information, you can compare insurers and plans to see what might work best for you. You likely need the following information to enroll in a dental PPO plan:

• Name
• Birth date
• Social Security number
• Proof of citizenship or residency
• Income information, including access to tax returns
• Current insurance information, if applicable

Many insurers, including MetLife, offer an online portal that guides you through the process. Begin by entering your information and submitting it. Confirm your enrollment or contact customer service if you’re not sure you’re properly enrolled.

If the insurer offers an app, download it, or log into your insurer’s online dashboard to manage your account and make sure you understand your benefits before you begin using them.

Costs and coverage of dental PPO plans

Factors that influence the cost of Dental PPO plans usually include premiums, deductibles, and copays. You can usually reduce your premium by choosing a higher deductible.

Additionally, the maximum benefit provided by the insurer can influence cost. A lower maximum annual benefit often results in a lower monthly premium. However, if you reach your maximum, you might have to pay more out of pocket for additional services.

A dental PPO plan typically covers preventive care, such as routine cleanings, and might include some x-rays. Additionally, tooth sealing and fluoride treatment might be considered preventive care. Many plans cover preventive care up to 100%, incentivizing you to take better care of your oral health.

Besides preventive care, basic and major services might be covered based on the type of care you get.

• Basic: These services can include diagnostic x-rays, fillings, simple extractions, some root canals, and root planing.
• Major: When procedures are more complex, they might cost more. These can include impacted tooth extractions, crowns, bridges, dentures, and orthodontics. Additionally, if you receive sedation for your procedure, it might be considered major.

It may be helpful to use an online dental cost calculator, if your insurer offers it, to estimate the cost of procedures and how much you might pay based on your coinsurance rate. You can also check how much a procedure will cost by getting an estimate from your dental insurer before you schedule it.

Maximizing your dental PPO plan benefits

If you want to get the most out of your dental PPO plan, start with regular preventive care. There’s a good chance you won’t have to pay for most routine cleanings and check-ups, and that can reduce the need for future basic and major dental services.

Next, look for in-network providers. For instance, MetLife has an extensive network of providers, and they can also help you find a dentist with the SpotLite on Oral Health designation. This designation is given to in-network providers that meet certain criteria for preventive oral health care. Choosing one of these providers may help you identify a dentist who is likely to catch problems before they become more expensive.

Is a dental PPO plan right for you?

Before deciding on a dental insurance plan, understand your care needs and consider what matters most to you. A PPO plan can be a good choice if you want the flexibility to choose your providers, as well as the ability to choose from levels of coverage that fit your budget. Dental PPO plans’ flexibility can make them a good choice for individuals, families, and seniors.

Pay attention to plan features so you can take advantage of the best available coverage. Understand how to use the insurance company’s portal to access benefits, review claims, and find dentists that fit your oral health care needs and budget.