Understanding Dental Insurances & Programs

Understanding HMO

Dental insurance form.

HMO, or Health Maintenance Organization, is a type of dental insurance where the patient is appointed an approved network provider. The patient is free to appoint any provider that is approved by the HMO; however, they must first need to change their appointed provider to the new provider with the insurance company before they can go see the new provider. It may take a few days to a few weeks for the appointment process to be completed. If you see a dentist that is not contracted with your HMO plan or you do not want to wait until the appointment process is completed, you can still be seen but you will be charged at the full office fee rate.

HMO plans typically have cheaper monthly premiums compared to PPO plans; therefore, the low premiums can only cover for the bare minimum materials and services. HMO plans tend to have weaker coverage on procedures and covers for mostly basic materials. Patients will typically need to pay extra fees for better quality materials and procedures.

With an HMO dental insurance plan, your insurance benefits can only be effective when both of the following conditions are met:

  1. Dentist within your HMO network AND
  2. You are assigned to that dentist or dental office.

To get assigned, you simply contact your HMO insurance and ask them to assign you to the office of your choice. Once the assignment is completed (may take a few days to a few weeks), the dental office will be able to verify your HMO insurance information. If you see a dentist that is not contracted with your HMO plan or you do not want to wait until your HMO information is verified, you can still be seen but you will be charged as at full office rate.

Understanding PPO

PPO, or Preferred Provider Organization, is a type of dental insurance that provides the most flexibility to the patients and often, better coverage and benefits.  Under a PPO dental insurance plan, you have the freedom to choose any dental provider you wish. Of the providers that you choose, there will be an in-network provider and an out-of-network provider. You may receive a higher level of coverage if you see a provider who is considered “preferred” or in-network. If you choose to see a dental provider outside of the PPO network, you can still receive coverage but at a slightly higher fee.

As far as the costs, PPO dental insurance plans typically have higher premiums than HMO dental insurance plans, but they also tend to have more comprehensive coverage and pay a portion of the costs on behalf of the patient. Most PPO dental insurance plans may cover a wider range of procedures and may have higher coverage limits for certain services.

Furthermore, the financial cost is shared between the insurance company and the patient. For a PPO dental insurance, you are generally paid a copayment for each covered dental service you receive. The copayment will be a small percentage of the total cost of the service and the insurance companies typically pay the other portion of the total cost of the service on behalf of the patient. The patient will be responsible for paying any remaining balance after your insurance has been applied if there is still any.

PPO dental insurance plans may also have an annual maximum benefit, which is the maximum amount of coverage the plan will provide in a given year. Once you reach the annual maximum benefit, you may have to pay out of pocket for any additional dental services you receive. PPO plans also have a deductible, which is the minimum charge the patient must pay before your insurance starts sharing costs with the patient. Most common deductible amounts for PPO dental insurance is typically $25-100. 

Understanding Lumi Membership

Dental Membership Plan is an alternative to dental insurance that is offered by a few dental offices. With an in-house dental membership plan, patients typically pays an annual fee to receive a set of dental services for a reduced rate. Under an in-house dental membership plan, patients typically receive some preventive care services, such as routine cleanings, x-rays, and routine exams, at no additional cost. Any treatment like fillings or crowns will receive a reduced fee rate. They are highly affordable for patients who do not have dental insurance or who have limited dental insurance coverage.

We understand that not everyone has dental insurance as it can be costly to maintain. Our office created the Lumi Membership Program (hyperlink to Lumi Membership Plan) with the intention to help the uninsured patients get access to more savings and better coverage for procedures. If you have any questions about our Lumi Membership Program, please reach out to our staff and office and we will be happy to answer any questions you may have.