Types Of Dental Insurance

HMO (Health Maintenance Organization)

This involves picking a dentist out of a list provided by your employer or insurance company. Once you pick that dentist, you must go to that dentist unless you notify your insurance company that you wish to change dentists.

With this type of plan, you do NOT have the freedom to go "out-of-network." If you do for any reason, you are, in all likelihood, not covered for that treatment, and any expenses incurred are your responsibility. These plans usually require that you present some sort of membership card to the dentist and have minimal forms and paperwork.

Please note, we do NOT participate with any HMO/DMO-type dental plans.

PPO (Preferred Provider Organization)

This means that both you and your insurance company would prefer that you see a "network" dentist. This is a dentist that has agreed to charge members a set fee for each procedure, even if that fee is lower than his/her regular fee. The insurance company then pays a percentage of that fee. If the percentage is not 100%, you are responsible to pay the remainder (out-of-pocket) to the dentist.

In many cases, PPOs allow you to go "out-of-network." But remember, the out-of-network dentist is not obligated to honor the lower fee because he or she has not entered into an agreement with the insurance company. Therefore, if you choose to go out-of-network, your "out-of-pocket" expense could be higher.

These plans may also have a membership card and usually involve an insurance form that must be filled out and sent to the insurance company for payment.

Traditional Indemnity

This type of insurance affords you the most freedom. You do not have to choose any one dentist and the insurance company has no preference as to whom you see for your treatment.

The dentist charges his or her regular fee and the insurance company pays a percentage of that fee. If the percentage is not 100%, then you are responsible for the balance of the fee.

With this type of insurance, companies use something called UCR - which stands for Usual, Customary and Reasonable. For example, the same filling done at an office on the upper east side of Manhattan, and at an office in New Brunswick may have a vastly different fee. To avoid confusion, your insurance company will pay a percentage of what it feels is UCR for that procedure. Even if the Manhattan doctor's fee is way above UCR, you are still responsible for the balance of that fee - the insurance company does not govern the fee since they have not entered into an agreement with that doctor.

With this in mind, it is probably advisable to know how close to UCR your dentist's fees are. You could be paying more than you have to.