PPO Dental Plans

PPO dental plans are by far the most widely available and most popular dental insurance plans. They offer their members the most freedom and the largest benefit. Dental offices perform treatment, fill out insurance claim forms, and mail them to the insurance company for processing and claim payment. The costs of dental care are covered by both the patient and the insurance company.

A typical PPO plan offers its members a yearly maximum benefit amount and the freedom to choose just about any dentist they'd like to see. Below are some important things to note about PPO plans.

Benefit Amount
Most PPO dental plans offer between $1000 and $2000 per year in dental benefits. Most patients assume that any treatment they need will be covered by that yearly maximum before any out of pockets costs are incurred. This is not the case with most PPO dental plans. Typical coverage of dental work is as follows:

Preventative and Diagnostic Needs
Preventive and Diagnostic needs (routine cleanings and x-rays) are usually covered at 100% meaning the insurance pays for the cost of treatment in full up to the yearly maximum.

Basic restorative needs (fillings and extractions) are usually covered between 60% and 80% meaning that is the cost of treatment is $100, the insurance will cover $60 to $80 of the total treatment cost up to the yearly maximum. This leaves the patient with some out of pocket costs. Keep in mind that deductible amounts exist and that these amounts are covered by the patient (usually $25-$100 of the first procedure performed).

Major restorative needs (crowns and dentures) are typically covered between 40% and 50% meaning that around half of the cost of treatment is covered by the insurance company up to the yearly maximum and the rest by the patient.

Exclusions
A major downside to PPO dental insurance plans are the exclusions that are placed in each members plan. These exclusions are determined when your employer negotiates with the insurance company to determine the cost of premiums. These exclusions can range from pre-existing condition clauses to reduced coverage amounts for certain procedures to elimination of procedures from the list of covered treatment. It is important to note that the dental office has no knowledge of these exclusions and cannot obtain a list of them from the insurance company. It is very important that members read their benefits handbook and familiarize themselves with their insurance coverage before treatment is started to minimize financial surprises after treatment is finished. It is also important to note that in the eyes of your dental insurance company, the dental office where you receive your treatment is only there to provide treatment and has no influence on which procedures are covered or the percentage at which they are covered.

PROS

• The ability to see the dentist of your choice
• Lower out of pocket treatment costs
• More options for treatment CON'S
• Higher cost for monthly premiums
• Employers may not offer a PPO option

CONS 

• Higher cost for monthly premiums
• Employers may not offer a PPO option