Offered PPO and DMO dental plans. PPO is 3x more expensive but I can't determine benefits

[thrump]

I was offered wo plans from Aetna, DMO Plan 65 and PPO Dental (no additional identifying information for policy)

I don't understand why the PPO plan is so much more expensive because it caps coverage per year at $1500 and it groups expenses as type "A", "B", "C" without dicating what types of expenses fall into each category. Coinsurance for the categories are 100%, 80%, and 50%

Meanwhile, the DMO plan details different services and specifically dictates the copayment amount for each service. It also doesn't dictate a plan maximum amount.

It looks like the DMO plan is the better and less expensive plan, but I don't know anything about insurance so I can't tell why the PPO plan is more expensive and seemingly worse coverage.

Schedule of Benefits
(GR-9N-S-01-001-01 FL)
Employer:
Group Policy Number:
Issue Date:
November 8, 2018
Effective Date:
October 1, 2018
Schedule:
2A
Cert Base:
2
For: PPO Dental
This is an ERISA plan, and you have certain rights under this plan. Please contact your Employer for additional information.
Comprehensive Dental Plan (PPO)
Schedule of Comprehensive Dental Benefits (GR-9N-S-21-005-01) PLAN FEATURES NETWORK OUT-OF-NETWORK Calendar Year Deductible Individual $50 Family $150 Individual $50 Family $150
The Calendar Year deductible applies to all covered expenses except Type A Expenses.
(GR-9N-S-21-010-01)
Please refer to the listing of covered expenses and the percentage payable appearing below. The percentage the plan will pay varies by the type of expense.
PLAN COINSURANCE NETWORK COINSURANCE OUT-OF-NETWORK COINSURANCE Type A Expenses 100% 100% Type B Expenses 80% 80% Type C Expenses 50% 50%
Calendar Year Maximum Benefit (GR-9N-S-21-010-01)
Calendar Year Maximum:
$1,500
The most the plan will pay for covered expenses incurred by any one covered person in a Calendar Year is called the Calendar Year Maximum Benefit.
The Calendar Year maximum benefit applies to network and out-of-network covered dental expenses combined.
GR-9N 2
Expense Provisions (GR-9N-S-09-05-01 FL)
The following provisions apply to your health expense plan.
This section describes cost sharing features, benefit maximums and other important provisions that apply to your Plan. The specific cost sharing features and the applicable dollar amounts or benefit percentages are contained in the attached health expense sections of this Schedule of Benefits.
The insurance described in this Schedule of Benefits will be provided under Aetna Life Insurance Company's policy form GR-29N.
Keep This Schedule of Benefits With Your Booklet-Certificate.
Deductible Provisions (GR-9N-S-09-05-01 FL)
Network Calendar Year Deductible
This is an amount of network covered expenses incurred each Calendar Year for which no benefits will be paid. The network Calendar Year deductible applies separately to you and each of your covered dependents. After covered expenses reach the network Calendar Year deductible, the plan will begin to pay benefits for covered expenses for the rest of the Calendar Year.
Out-of-Network Calendar Year Deductible
This is an amount of out-of-network covered expenses incurred each Calendar Year for which no benefits will be paid. The out-of-network Calendar Year deductible applies separately to you and each of your covered dependents. After covered expenses reach the out-of-network Calendar Year deductible, the plan will begin to pay benefits for covered expenses for the rest of the Calendar Year.
Covered expenses applied to the out-of-network deductible will be applied to satisfy the network deductible and covered expenses applied to the network deductible will be applied to satisfy the out-of-network deductible.
Network Family Deductible Limit
When you incur network covered expenses that apply toward the network Calendar Year deductibles for you and each of your covered dependents these expenses will also count toward the network Calendar Year family deductible limit. Your network family deductible limit will be considered to be met for the rest of the Calendar Year once the combined covered expenses reach the network family deductible limit in a Calendar Year.
Out-of-Network Family Deductible Limit
When you incur out-of-network covered expenses that apply toward the out-of-network Calendar Year deductibles for you and each of your covered dependents these expenses will also count toward the out-of-network Calendar Year family deductible limit. Your out-of-network family deductible limit will be considered to be met for the rest of the Calendar Year once the combined covered expenses reach the out-of-network family deductible limit in a Calendar Year.
Covered expenses applied to the out-of-network deductible will be applied to satisfy the network deductible and covered expenses applied to the network deductible will be applied to satisfy the out-of-network deductible.
Copayments and Benefit Deductible Provisions (GR-9N-09-015-01 FL)
Copayment, Copay
This is a specified dollar amount or percentage, shown in the Schedule of Benefits, you are required to pay for covered expenses.
GR-9N 3
Coinsurance Provisions (GR-9N S-09-020 01)
Coinsurance
This is the percentage of your covered expenses that the plan pays and the percentage of covered expenses that you pay. The percentage that the plan pays is referred to as the “Plan Coinsurance”. Once applicable deductibles have been met, your plan will pay a percentage of the covered expenses, and you will be responsible for the rest of the costs. The coinsurance percentage may vary by the type of expense. Refer to your Schedule of Benefits for coinsurance amounts for each covered benefit.
Maximum Benefit Provisions (GR-9N S-09-025 01)
Calendar Year Maximum Benefit
The most the plan will pay for covered expenses incurred by any one covered person in a Calendar Year is called the Calendar Year maximum benefit.
The Calendar Year maximum benefit will not deny benefits for certain covered expenses in any one Calendar Year.
The Calendar Year maximum benefit applies to network care and out-of-network care expenses combined.
General (GR-9N-28-01-01-FL)
This Schedule of Benefits replaces any similar Schedule of Benefits previously in effect under your plan of benefits. Requests for coverage other than that to which you are entitled in accordance with this Schedule of Benefits cannot be accepted. This Schedule is part of your Booklet-Certificate and should be kept with your Booklet-Certificate form GR-9N. Coverage is underwritten by Aetna Life Insurance Company.

Schedule of Benefits
(GR-9N-S-01-001-01 FL)
Employer:
Group Policy Number:
Issue Date:
November 8, 2018
Effective Date:
October 1, 2018
Schedule:
1A
Cert Base:
1
For: DMO PLan 65
This is an ERISA plan, and you have certain rights under this plan. Please contact your Employer for additional information.
Managed Dental Plan
Schedule of Managed Dental Benefits (GR-9N-22-005-02 FL)
This Schedule Applies to Covered Expenses Provided by Network Providers.
Office Visit Copayment
$5 per visit.
Dental Emergency Maximum:
$100
Dental Care Schedule
The following dental care schedule shows services that require a copay; and the copay amount.
Dental services that are considered covered expenses as shown in the dental care schedule must be given by network providers, at the dental office location. The exceptions to this rule are when Aetna approves referral care, or for out-of-area emergency dental care.
In addition to copays for covered expenses shown in the following schedule, you will also be responsible for an office visit copay as shown above.
If:
 A charge is made for an unlisted service given for the dental care of a specific condition; and
 The list includes one or more services that, under standard practices, are separately suitable for the dental care of that condition, then the charge will be considered to have been made for a service that would have produced professionally acceptable result, as determined by Aetna.
GR-9N 2
This Schedule Applies to Services Provided by Network Providers
Primary Care Dentist Services (GR-9N-S-22-010-01)
Visits and Exams
Copayment Amount
Oral examination (limited to total of 4 visits per year)
$0
Emergency palliative treatment
$10
Prophylaxis (cleaning), (limited to 2 treatments per year)
Adult
$0
Child
$0
Topical application of fluoride (limited to 1 treatment per year and to covered persons under age 16)
$0
Oral hygiene instruction
$0
Sealants, per tooth (limited to 1 application every 3 years for permanent molars and to covered persons under age 16)
$0
Pulp vitality test
$0
Consultation
$0
Diagnostic casts
$0
X-Rays and Pathology
Bitewing x-rays (limited to 1 set per year)
$0
Entire series, including bitewings, or panoramic film, (limited to 1 set every 3 years)
$0
Vertical bitewing X-rays (limited to 1 set every 3 years)
$0
Periapical x-ray
$0
Intra-oral, occlusal view, maxillary or mandibular
$0
Extra-oral upper or lower jaw
$0
Accession of oral tissue
$0
Space Maintainers - (only when needed to preserve space resulting from premature loss of primary teeth) Includes all adjustments within six months after installation
Fixed
$0
Removable
$0
Recement space maintainer
$12
Remove fixed space maintainer (by dentist who did not place appliance)
$12
Endodontics
Pulp cap
$0
Pulpotomy
$0
Root canal therapy, including necessary x-rays
Anterior
$50
Bicuspid
$70
Restorations and Repairs (Copayments for crowns and pontics are per unit.) There will be an additional patient charge for the actual cost of high noble metal ("gold") when used for services shown with an asterisk.
Amalgam restoration
1 surface
$0
2 surfaces
$0
3 surfaces
$0
4 or more surfaces
$0
GR-9N 3
Resin-based composite restoration (anterior)
1 surface
$0
2 surfaces
$0
3 surfaces
$0
4 or more surfaces or incisal angle
$40
Resin-based composite crown, anterior
$40
Resin-based composite restoration (posterior)
1 surface
$35
2 surfaces
$45
3 surfaces
$55
4 or more surfaces
$75
Retention pins
$10
Stainless steel crowns, prefabricated, primary tooth
$0
Stainless steel crowns, prefabricated, permanent tooth
$40
Recementing inlays or crowns
$5
Recementing bridges
$15
Sedative filling
$0
Inlays metallic*
$190
Crowns
Porcelain
$225
Porcelain with metal (includes abutments)*
$225
Metallic (full cast) (includes abutments)*
$225
Metallic (3/4 cast)*
$225
Cast post and core*
$80
Prefabricated post and core
$70
Core buildup including pins
$60
Pontics
Metallic (full cast)*
$225
Porcelain with metal*
$225
Full mouth rehabilitation, per unit (This means 6 or more covered units of crowns and/or pontics under one treatment plan.)
$125
Dentures and Partials - (Includes relines, rebases and adjustments within six months after installation. Adjustments within first six months are limited to four.)
Complete, upper or lower
$275
Partial, upper or lower
Resin base
$275
Cast metal base
$325
Immediate, upper or lower (does not include charge for reline)
$325
Adjust complete denture, upper or lower
$10
Adjust partial denture, upper or lower
$10
Repair broken acrylic, complete denture, upper or lower
$30
Replace one tooth on complete denture
$35
Repair resin denture base, cast frame, broken clasp
$35
Replace broken tooth, partial
$35
Add tooth to existing partial denture
$35
Add clasp to existing partial
$40
Replace all teeth and acrylic on cast metal framework
$100
Rebase, complete denture, upper or lower
$100
Rebase, partial denture, upper or lower
$100
Reline, complete denture, upper or lower (chairside)
$40
Reline, partial denture, upper or lower (chairside)
$40
Reline, complete denture, upper or lower (laboratory)
$90
Reline, partial denture, upper or lower (laboratory)
$90
GR-9N 4
Interim partial denture, upper or lower (stayplate), anterior only
$90
Tissue conditioning for dentures
$40
Periodontics
Scaling and root planing, per quadrant (limited to 4 separate quadrants every 2 years)
$50
Scaling and root planing -1 to 3 teeth per quadrant (limited to once per site every 2 years)
$30
Periodontal maintenance procedures following surgical therapy (limited to 2 per year)
$30
Occlusal guard (for bruxism only), limited to 1 every 3 years
$100
Oral Surgery - Includes local anesthetics and routine post-operative care
Extraction - exposed root or erupted tooth
$0
Extraction - coronal remnants - deciduous tooth uncomplicated
$0
Surgical removal of erupted tooth
$0
Surgical removal of impacted tooth (soft tissue)
$0
Incision and drainage of intraoral abscess
$10
Mobilization of erupted or malpositioned tooth to aid eruption.
$30
Biopsy of oral tissue
$50
Specialty Services
Copayment Amount
Endodontics - Includes local anesthetics where necessary
Apicoectomy/periradicular surgery
Anterior
$65
Bicuspid, first root
$65
Molar, first root
$80
Each additional root
$40
Retrograde filling, per root
$20
Root amputation, per root
$60
Molar root canal therapy
$175
Retreatment of previous root canal therapy
Anterior
$150
Bicuspid
$170
Molar
$275
Oral Surgery - Includes local anesthetics where necessary and post-operative care
Surgical removal of residual tooth roots
$15
Frenectomy
$24
Alveoloplasty in conjunction with extractions - per quadrant
$18
Alveoloplasty not in conjunction with extractions - per quadrant
$25
Surgical removal of impacted tooth
Partially bony
$45
Completely bony
$70
Completely bony with unusual surgical complications
$70
Periodontics
Gingivectomy or gingivoplasty - per quadrant, limited to 1 per quadrant, every 3 years
$100
Gingivectomy or gingivoplasty - 1-3 teeth, limited to 1 per site, every 3 years
$30
Gingival flap procedure - per quadrant
$110
Gingival flap procedure - 1-3 teeth one per quadrant
$66
Occlusal adjustment (other than with an appliance or restoration)
Limited
$20
Complete
$80
Osseous surgery (including flap entry and closure) - per quadrant, limited to 1 per quadrant, every 3 years
$250
GR-9N 5
Osseous surgery (including flap entry and closure) - 1 to 3 teeth, limited to once per site every 3 years
$150
Surgical revision procedure, per tooth
$100
Pedicle soft tissue graft
$190
Free soft tissue graft (including donor site surgery)
$205
Subepithelial connective tissue graft
$115
Soft tissue allograft
$230
Combined connective tissue and double pedicle graft
$190
Clinical crown lengthening - hard tissue
$150
General Anesthesia and Intravenous Sedation - (only when provided in conjunction with a covered surgical procedure)
Deep sedation/General Anesthesia
First 30 minutes
$165
each additional 15 minutes
$70
Intravenous conscious sedation/analgesia
First 30 minutes
$165
each additional 15 minutes
$70
Orthodontics
Limited to treatment of cleft lip or cleft palate for a child under age 18
**
Oral Surgery – Includes local anesthesia where necessary and post-operative care
Cleft lip or cleft palate surgery for a child under age 18
**
**An amount to be determined which is consistent with other covered services in this section as shown in this Schedule of Benefits.
Expense Provisions (GR-9N-S-09-05-01 FL)
The following provisions apply to your health expense plan.
This section describes cost sharing features, benefit maximums and other important provisions that apply to your Plan. The specific cost sharing features and the applicable dollar amounts or benefit percentages are contained in the attached health expense sections of this Schedule of Benefits.
The insurance described in this Schedule of Benefits will be provided under Aetna Life Insurance Company's policy form GR-29N.
Keep This Schedule of Benefits With Your Booklet-Certificate.
Copayments and Benefit Deductible Provisions (GR-9N-09-015-01 FL)
Copayment, Copay
This is a specified dollar amount or percentage, shown in the Schedule of Benefits, you are required to pay for covered expenses.
General (GR-9N-28-01-01-FL)
This Schedule of Benefits replaces any similar Schedule of Benefits previously in effect under your plan of benefits. Requests for coverage other than that to which you are entitled in accordance with this Schedule of Benefits cannot be accepted. This Schedule is part of your Booklet-Certificate and should be kept with your Booklet-Certificate form GR-9N. Coverage is underwritten by Aetna Life Insurance Company.

 

[fmontanay2]

@thrump Word of caution is the DMO networks can be extremely limited and tough to get appointments.

 

[thrump]

@fmontanay2 You were right, unfortunately. The only provider in 50 miles only has appointments available in May.

 

[lizzie18]

@thrump Unlike Medical Insurance, at least post-1970s Medical Insurance, Dental HMOs and Dental PPOs work very differently in how the dentist is paid.

PPO:

• There is a contractually agreed price for each ADA (dental) or CPT (medical) code your insurance covers, which in-network dentists in the same county or ZIP code charge.
  • Your plan might cover the dentist under more than one network (e.g. Delta Premier and Delta PPO).
  • Always check that they take the one you actually have and won't be able to bill the more expensive one (allowed in some states/cases).
• The plan will not spend more than the plan maximum in any given year, the difference is on you.
  • In some states, although this number is decreasing, the in-network/discounted price still applies if the insurer doesn't cover something because either A) they paid too much or B) you bought a lower-tier plan than one that does.
• Depending on the type, you might owe some or none of those costs.
  • Preventive (i.e. cleanings, exams, and imaging): Usually covered a set number of times a year at no cost to you.
    • Depending on plan, this might still count against the plan spending but that is less common these days.
  • Basic: which usually includes non-surgical treatments like fillings, root planing, and gum treatments. Covered at a set percentage once you pay the deductible.
    • NOTE: Some services have a repeat clause. I.e. if you get a filling and it fails or you break it, the plan won't pay to replace it unless it was done a set number of months ago.
    • Simple extractions can also fall under this, depending on where the tooth is and if the gum needs to be rebuilt.
  • Restorative: Includes crowns, onlays (partial crown), and (most plans) non-fixed dentures.
    • Some plans also cover implants and fixed dentures, but it's rare and often limited to dentists (not prosthodontists, who do complex ones).
  • Surgical: As the name implies, this is for anything that requires a physical change or adjustment to your gums or jaw.
  • Orthodontics (braces) and Endodontics (tooth salvaging, e.g. root canal) are their own categories. These have lifetime limits for you, for the former, and per tooth (the latter).

DHMO (aka DMO). A McDonald's-eque capitation plan.

• The plan picks a narrow network of general dentists, and the few specialists willing to play ball, and pays them based on how many patients they see in a month (hence capitation). What the patients are seen for does not matter because...
• You will pay the fixed copay when you get a service done. Ideally, it's supposed to cover the added supplies and complexity.
  • In most cases, it only covers the former so dentists HATE it and usually only take it if part of a chain dental clinic. Some chain dental clinics (e.g. Aspen) are outright scams too.
  • That is why they often push more services, or ones not covered, than a solo-practice dentist does for their patients. Also, why specialists don't take HMO plans.
• There is hypothetically no limit to how many copays you can pay in a year, along with no plan maximum or waiting period. How many dentists want to perform, however, is another discussion.

 

[thrump]

@lizzie18 Aetna's website doesn't include the option to pick the DMO plan while looking up providers. This is deeply problematic.

I hate this. I feel like I'm being forced to choose between only bad options.

 

[lizzie18]

@thrump DMO/DHMO is further down the list, but you'll need to know the networks full name. Should be listed in the benefits guide (e.g. "access to X") or you can call the benefits hotline at your employer.

https://www.aetna.com/dsepublic/#/contentPage?page=providerSearchLanding&site_id=dse&language=en

 

[thrump]

@lizzie18 Thank you for this, when I went to their website selected dental services before selecting plan type, it refused to show me anything other than PPO.