Understanding What Referrals Mean

Most networks have their own rules about whether you can contact a physician on your own or if it’s best left to your personal healthcare provider, also known as your ‘gatekeeper.’

• While it is easy to make an appointment, if your health plan requires a referral beforehand, then it won’t cover the cost of your appointment without your physician’s prior approval.
• Once you get their approval, you can finally reduce your treatment costs.

What Are HMO Plans?

HMO or Health Maintenance Organization is a network of healthcare providers who have agreed to reduce their rates for network members. Medical coverage is only provided to individuals who are in the network. This means if you visit a doctor or hospital out-of-network, your insurance provider won’t cover any medical expenses and you will most likely have to pay the entire bill yourself.

• HMO members are required to choose a gatekeeper, or Primary Care Provider, who is authorized to refer them to network specialists (dermatologists, pathologists, cardiologists, or others). The gatekeeper plays an important role because they check patients for possible health issues and then refer them to the appropriate care providers.
  In a way, this ensures you’re getting the right person for your potential medical issue. Sometimes, the primary care provider might treat the patient in their own clinic without having to visit another physician.
• HMO plans are a good choice for individuals who want the services of a central doctor to make informed healthcare decisions on their behalf.
  Patients who are usually out of town might be at a disadvantage because they may not find healthcare providers from their own networks.
• Most people prefer HMO plans because of the low monthly premiums with little to no deductibles that they offer.
• The biggest disadvantage with HMOs is the long waiting times, with some patients having to wait at least a few weeks or even months before their next appointment. Another big advantage with dental HMO plans is that the insured individuals don’t have to worry about filing any claims, since their primary care provider will file it on their behalf.
• Dental HMOs don’t have annual calendar maximums, which is the maximum amount an insurance carrier is willing to contribute to your overall dental bill in a specified period of time. Insured individuals can use their benefits throughout the year. DHMO dental insurance plans are mostly used by business to provide healthcare to their employees, but these plans can be used by families and individuals as well.

What Are PPO Plans?

PPO or Preferred Provider Organization (PPO) is a network that offers a lot more flexibility to individuals when choosing specialists and dentists. It is optional to choose a primary care provider, although rates are lower if the insured member opts for a primary dental specialist from within PPO network.

• Patients don’t need referrals to make appointment with their providers. There is the off-chance individuals might have to spend more for these visits.
• It is argued that PPO dental insurance plans offer superior quality of services with fewer limitations than HMO plans, but the premiums individuals have to pay is higher. Despite the high cost, individuals and families prefer using PPO dental insurance plans.
• Aside from higher premiums associated with dental PPOs in comparison to dental discount plans, PPOs also tend to have cumbersome claim forms that take forever to fill out. Insured members have to wait long before they can receive any reimbursements. Furthermore, insured members have to pay their deductibles before they can receive any reimbursements.
• Most PPO insurance plans only cover a portion of the specialist’s fee, requiring the patient to make a co-payment to cover the cost of their treatment. PPOs have annual calendar maximums, with the total amount varying from one insurance company or plan to another.
  

   

Which One Should You Choose?

There are several factors you should take into account before deciding one network over the other. If you live in an area where there aren’t many dentists within an HMO network or your preferred dentist is not a part of the network, then you are better off on a PPO plan.

If your job or business requires you to travel frequently, but you want to see a dentist while out of town, then your best bet would be a flexible PPO plan. This rule also applies to pharmacies, which means if they are out of the network of HMOs, they will not be included under the plan. In contrast, PPOs allow insurers to fill up their prescriptions in most areas.

Ultimately, however, the very aspect of choosing dental insurance is too difficult because individuals have so many options. It is difficult to give an outright verdict in favor of either of the networks because you can’t apply a one-size-fits-all rule to dental care.

It all comes down to personal choice. Insured individuals will have to wait long periods of time either way. Studies show that more individuals are members of PPO plans than HMO plans. In fact, at least 58 percent of workers opted for PPO while only 13 percent of those workers chose HMO. Although PPOs are more popular, a survey shows that individuals are more satisfied with their HMO plans.