A PPO dental plan works just like your health plan, meaning you have in-network and out-of-network benefits. With a PPO dental plan, you must determine the benefit amount during the application process. You can buy a plan with a benefit of $750, $1,000, $1,500, $2,000, or $2,500. This is the maximum annual benefit that the insurance company pays every policy year. As long as you remain within the sum of the annual benefit, you’re covered. However, if you do exceed the annual benefit for the year, then you’ll have to wait until the next plan year to use the coverage.
The benefits covered within this type of dental plan are categorized accordingly:
- Preventative: cleanings
- Basic: fillings and extractions
- Major: root canals, crowns, dentures, oral surgery, etc.
For preventative services, there’s usually no waiting period, whereas basic services usually have about a three-month (sometimes five/six-month) waiting period. Lastly, major dental services have anywhere from a six month to a year long waiting period.
In addition to waiting periods, PPO dental plans also have deductibles. The deductible is usually waived for preventative services, as cleanings are typically covered 100% within the network. Outside of the network though, the in-network, negotiated rate is forfeit; so instead of being free, the cost of a cleaning will be split 80/20.
As for basic services, you’ll have to meet a deductible once the waiting period is over. Once the deductible is met, the cost is split 80/20. For example, if you underwent a few fillings or extractions, the bill may be $500; if the deductible is already met, then the insurer would cover 80% of the $500 so you’d only have to pay $100. Using out-of-network providers changes the costs. The basic services – totaling $500 in-network – may cost $750 or $800 out-of-network, which is then split 50/50. Instead of the 80/20 split in-network, the insurer only pays for half of out-of-network services.
In regards to major dental services, the cost is typically split 50/50 in-network once the waiting period is over and the deductible is met. So if you undergo a root canal or oral surgery, the total cost of the procedures – let’s say it costs $1,500 – would be split down the middle; the cost to you will only be $750.
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