/  Members
    
/  How Your Dental Plan Works

How Your Dental Plan Works

What do you get when you buy a dental plan? Just like health insurance, you get access to a network of dentists and coverage for care and treatment you receive.

Learn more about affordable dental plans through HMSA.

Provider network: trusted dentists

Every dental plan has a network, which is a group of dentists that works closely with an insurer to serve its members. With most dental plans, you can get care from a dentist who’s either a participating or nonparticipating in the network. Participating providers have a contract with the insurance plan to provide services at a set fee. You can see a nonparticipating provider (someone who’s not in our network), but you may pay more than if you were to see a participating provider. Participating providers also file claims on your behalf. Learn more about provider networks.

If you’re an HMSA PPO member, you can choose a dentist from an extensive local network with more than 90% of dentists in Hawaii. If you’re on the Mainland, you can see a dentist in the Blue Cross Blue Shield network who’s considered a participating provider.

If you’re an HMSA HMO member, you’ll have access to providers in the Hawaii Family Dental network , the largest group dental practice in Hawaii.

Coverage for dental services

The basic purpose of insurance is to provide coverage for certain events that might happen. Your auto insurance provides coverage in a car crash, for example, which means it will pay a portion of the cost to fix your car. The payment is in the form of a claim. Likewise, dental insurance provides coverage for services such as a crown to repair a damaged tooth. Dental services generally fall into three categories:

  • Preventive: Most dental plans cover preventive care at 100%. This includes exams, cleanings, and X-rays. With some plans, preventive services for children, such as sealants, are covered at no additional cost.
  • Basic services: Treatment for gum disease, extractions, fillings, and root canals is considered basic. Most dental plans will pay most of the cost of these services, while you’ll be responsible for a portion of the cost in the form of a copayment or coinsurance.
  • Major procedures: Crowns, bridges, inlays, and dentures require a higher copayment or coinsurance than for basic procedures.

Some plans may include coverage for orthodontia, such as braces or dental implants. Check your plan’s Guide to Benefits before you receive services.

Various dental plans may categorize dental services differently. Make sure to check your plan’s Guide to Benefits before you receive services.

What you pay for dental insurance

Like most types of insurance, you must make regular payments to get and keep your coverage. This is called a premium. There are cost-sharing payments called “out-of-pocket expenses” that you may need to pay for certain treatments. Unlike premiums, out-of-pocket expenses are tied to services you receive and they help keep premiums more affordable for everyone.

  • Premiums: The amount you pay monthly for your dental plan.
  • Cost sharing or out-of-pocket expenses:
    • Deductible: A fixed amount you may need to pay for covered services before your insurance plan begins paying.
    • Copayment: A fixed amount you pay at each visit to the dentist. Copayments don’t apply to your deductible.
    • Coinsurance: A percentage of the cost for a service.

All plans require premium payments and many have a deductible. All plans have either a copayment or coinsurance for some services. Various plans with different payments give you more options to find a plan that works best for your financial situation.

Out-of-pocket costs are often capped for pediatric dental coverage. This is called a maximum out-of-pocket and is the total amount you’ll pay for dental care during a calendar year. Coverage for adults usually doesn’t have a maximum out-of-pocket.

Types of dental plans

Preferred Provider Organization (PPO) and health maintenance organization (HMO) plans are two of the most common types of dental—and health—insurance. The biggest differences between PPOs and HMOs are the premiums, the need to get referrals to see specialists, and benefit limits.

Dentists in PPO networks have a contract with insurance companies to offer services at a set fee. PPO networks are usually larger than HMO networks.

HMOs tend to charge lower monthly premiums. HMO networks also have a contract with us to offer services at set rates.

PPO/HMO Network Comparison Chart

PPOHMO
Choosing a DentistSee any dentist and get discounts on services when you visit participating providers.Benefits apply only when you see participating providers. You must also select a primary dentist.
Referrals to a specialistNot required.Your primary dentist must refer you to a specialist.
How you payA percentage of the cost is paid when you meet your annual deductible. Copayments may apply for some plans.You pay a set copayment at each visit.
Annual maximumYes, but some plans allow you to rollover unused benefits.No.
AdvantagesFlexibility—see the dentist of your choice, in- or out-of-network.

Larger networks of dentists.

No referral needed to see specialists.
Lower monthly cost.

No annual maximum.
Limitations/considerationsHigher monthly cost.Primary dentist must refer you to specialists.

Benefits don’t apply if you see a nonparticipating provider (a dentist who’s not in the network).

If you have a dentist, check our provider directory to see if your dentist is in our PPO or HMO network.

Other important factors

Annual maximum benefits

PPO dental plans typically have a yearly limit on what the plan will pay for services. According to the National Association of Dental Plans (NADP), only 9% of people who have a dental plan reach their annual maximum benefit. If you do, however, you may be responsible for paying costs over the maximum.

For members of many group PPO plans, HMSA offers a Calendar Year Rollover that lets you save unused benefit dollars for the following year. This can help you stay within the plan maximum.

Waiting periods

Some dental plans require you to wait for a period of time before you receive certain services. Review your policy to see if any waiting periods apply.

The benefits of dental coverage through HMSA

At HMSA, we offer a choice of affordable plan options to provide coverage to prevent issues and improve your dental health. When you need assistance, our Neighborhood Centers are staffed by employees who live and work on the islands, so we are here to serve you.

Learn more about our plans for individuals.