Dental Health Maintenance Organizations (DHMOs) offer members prepaid dental care with a focus on minimizing out-of-pocket expenses. Though benefits vary from policy to policy, DHMOs only cover preventative care and a handful of preapproved procedures received from in-network dentists or specialists.

DHMOs charge lower premiums than other forms of dental insurance and set no annual deductible or coverage maximum. Therefore, these dental plans make sense for people who want affordable protection for routine services like cleanings, X-rays, and exams. If a preferred dentist does not fall within your DHMO’s network or you have pressing oral health concerns, you may prove better off seeking more extensive benefits through a DPPO or other alternative.

How Does DHMO Insurance Work?

In exchange for a monthly premium, dental HMO insurance companies cover preventative care and preapproved procedures received from any in-network dentist they have under contract. While DHMOs reduce member out-of-pocket costs, they impose independent eligibility requirements, provide fewer covered services, and set more stringent restrictions than other forms of dental insurance.

Eligibility

Any healthy adult who can afford the monthly premiums can usually purchase DHMO insurance without having to clear any definitive hurdles. However, unlike medical insurance, the ACA does not have laws preventing dental insurers from denying coverage to people with preexisting conditions.

While the preventative focus of DHMO plans often makes preexisting conditions a non-issue, people with missing teeth, gum issues, or other pressing oral health concerns may encounter some enrollment complications.

Coverage

DHMOs focus on preventative care and dental maintenance. Routine services that meet these criteria almost always qualify for 100% coverage, including:

Oral exams
Teeth cleanings
Standard X-rays
Fluoride treatment
Sealants

DHMO patients who require basic restorative care like fillings, root canals, or extractions must pay a predetermined copayment for each service. Likewise, DHMOs only pay up to a specified amount – typically around 50% of the total cost – for major restorative procedures like crowns or implants. Some dental plans even partially cover in-network orthodontic care referred by your primary dentist.

These benefits and your share of out-of-pocket costs will vary from policy to policy, so ensure you find a DHMO that adequately matches your unique needs.

Coverage Limitations

All patients with HMO dental insurance must commit to a single primary care dentist under contract with their insurer. Policyholders must secure referrals from this primary dentist to guarantee treatment coverage from other in-network specialists, like orthodontists or periodontists.

DHMOs always deny coverage for cosmetic procedures, such as teeth whitening, veneers, or contouring. Some dental plans even classify braces and other orthodontic procedures as cosmetic services and withhold benefits.

How Much Does DHMO Insurance Cost?

Though premiums vary, an average DHMO plan costs around $32 a month and does not require members to pay a deductible. These policies do not impose an annual maximum, guaranteeing benefits for in-network covered services recommended by a primary dentist.

Most DHMOs pay for 100% of preventative care, charge small copayments for basic restorative care, and cover around 50% of more involved procedures. Even routine services like cleanings can cost up to $100 without insurance, so securing a DHMO often proves well worth the monthly premium.

Should You Get DHMO Insurance?

While DHMO plans offer many benefits, they may not suit everybody. Weigh all the relevant advantages and disadvantages before purchasing a policy.

Consider a DHMO Plan If…

You do not have preexisting dental conditions, like tooth decay or periodontal disease.
You can conveniently access local in-network providers.
Your preferred dentist is under contract with a DHMO insurer.
You want affordable dental insurance.
You already have relatively healthy teeth and gums.
You can afford to pay your monthly premiums on time.
You do not currently receive dental benefits through your employer or as part of another outside health plan.

Advantages

DHMOs present many of the following benefits:

No annual maximum for coverage
No deductibles
100% coverage for eligible preventative services like cleanings, X-rays, or exams
Lower monthly premiums than dental PPOs
Rarely impose post-enrollment waiting periods
Do not require policyholders to file their own claims
Only charge marginal copayments for minor, non-preventative procedures like fillings or extractions
Cover some major dental procedures, like crowns and root canals
Some plans include orthodontic services like braces, aligners, and retainers
Generally cheaper than most other forms of dental insurance
Help policyholders maintain their oral health and prevent more serious, costlier conditions from arising

Drawbacks

However, unlike dental PPO plans, DHMO insurance comes with the following limitations:

Only covers services from contracted dentists within a limited provider network
Patients must register with and receive the majority of their care from a primary dentist
To see an in-network specialist, patients must first secure a referral from their primary dentist
Some plans deny coverage to people with preexisting conditions
Focus heavily on preventative care and charge policyholders higher rates for restorative dental procedures
Patients must pay 100% of the cost for any service received out-of-network
Does not cover cosmetic procedures, like whitening or contouring
Plans typically include a narrower range of covered services

How to Get a DHMO Plan

Follow these steps to secure a favorable DHMO policy:

Determine coverage and costs. Compare covered services from various DHMOs to find a plan that matches your dental needs and budget.
Compare provider networks. Each DHMO covers services from different groups of dentists and specialists. Ensure you purchase a dental plan that makes care convenient and accessible.
Enroll in your policy. You can purchase a standalone DHMO policy on the Health Insurance Marketplace or directly from an insurance broker. Remember that some Marketplace and employer health plans already include reduced premium dental benefits.
Pay your premium. DHMOs rarely impose waiting periods, meaning you can find a primary dentist and begin receiving covered care immediately after paying your first bill.

DHMO vs. PPO Plans

While PPOs offer a more comprehensive range of benefits, they still resemble DHMOs in many ways. Primarily, each dental plan will cover 100% of preventative care. Likewise, DPPOs pay for restorative services, but typically at a set 100-80-50 rate – 100% coverage for routine maintenance, 80% for minor procedures, and 50% for major ones.

DPPOs almost always charge higher premiums than DHMOs. Unlike DHMOs, they typically impose deductibles, annual maximums, and waiting periods for specific services. DPPOs do not require patients to find a primary dentist and will even cover out-of-network care for a higher coinsurance or copayment. Review the chart below for a more in-depth comparison:

	DHMO	PPO
Eligibility	Most people are eligible. Can deny coverage for preexisting conditions.	Most people are eligible. Can deny coverage for preexisting conditions.
Coverage	Preventative care and some restorative procedures	Preventative care and a more comprehensive range of procedures
Copay	Yes	Sometimes
Deductible	No	Yes
Coinsurance	% of the flat rate for service	% of the contracted rate per dentist
Annual Maximum	No	Yes
Network	Must stay in-network.	Will cover out-of-network care at a higher coinsurance rate.
Waiting Period	No	Yes

Essentially, DHMOs make more sense for cost-conscious individuals with basic dental needs and access to a primary in-network dentist. PPOs better suit individuals who require more comprehensive care, want access to more providers, and can afford higher premiums, coinsurance, and deductible rates.

All in All

Because standard health insurance only sometimes includes dental care, many people must purchase standalone policies. If you want affordable coverage and only require routine and preventative services, a DHMO plan could adequately suit your needs and budget.

While cheap and convenient, these policies set varying restrictions on where and how you can receive care. Always compare a variety of DHMOs through the Health Insurance Marketplace or a private agency to ensure you secure a policy with relevant coverage and a convenient provider network.

Frequently Asked Questions

Yes. If you do not like the primary care dentist initially assigned to you, you can request a transfer to another provider. You can switch as many times as needed as long as you remain within your policy’s network.

Rarely, though this ultimately depends on your policy. Some DHMO plans occasionally require members to wait a month or longer before granting coverage for specific restorative procedures like fillings, crowns, or root canals.

Yes, as long as you enroll in family coverage. While adding family members to your DHMO will result in higher premiums, it will not invoke a deductible or annual maximum. DHMO family plans grant your spouse and children access to all the same benefits and typically prove cheaper than securing coverage for each person independently.

Suppose you are experiencing a dental emergency. In that case, a DHMO would lift its usual restrictions and allow you to receive potentially life-saving care from any convenient out-of-network provider. While covered, out-of-network emergency procedures still trigger a higher coinsurance than identical in-network care.

Occasionally. Some DHMO plans will cover standard orthodontic treatments like braces or retainers, typically for around 50% of the cost. Even so, policyholders would have to secure a referral to an in-network specialist from their primary care dentist. Notably, many plans still entirely exclude orthodontic care from coverage.

What Is a Dental Care (DHMO) Insurance Plan?

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