Insurance Decision-DMOs

Septus

I'm about at the end of my enrollment period for my dental insurance, and I have the option of switching from my current PPO, to an HMO. The only point of doing so would be to cover braces, since my current PPO does not cover that at all. Uncovered, it's $6500, and with an HMO it's about $2100. That's a huge difference, but considering the time involved, my own personal issues with having braces at my age, the discomfort and everything else, I really don't want to go through with this unless I'm getting a pretty damn good treatment.

That being said, I'm curious about anyone's experience with HMOs and how that payment method may affect treatment. Considering the limited number of providers, and the set dollar amount, I can't help but wonder if there will be pressure of some kind on the orthodontist to pursue less than optimum treatment methods. The orthodontist that I already visited with, the one that may very well be the best in town, but also terribly expensive, tells me that with my case, an HMO provider might push for a more standard ortho treatment, and then jaw surgery to finish it up. I'm taking that with a grain of salt because I'm being told this by the office that wants my money.

Anyone care to share their experience with quality of care for HMO providers?

Deebaser

This is actually about DMOs, not HMOs (HMOs cover everything other than the teeth and eyes). Sorry to nitpick, but here i am nitpicking.

I personally had shitty experience with an old DMO, but the fee scheduiles don't necessarily have to be garbage. I'm also assuming the for ortho there is still at least a 20% coinsurance. It all boils down to, whether or not there is a competant provider in your area that accepts your coverage.

The dentist will be providing your care, not his admin staff.

Enc

I've found that a PPO generally will pay for itself in the long run, but for dental? Compare total possible costs. Do you expect to have any massive mouth issues outside of the braces? If so, or if possible, you'll probably have to pay that 4k back on what is dumped on your lap from the HMO. Plus you'll have to beg, barter, and plead just to get them to follow through (traditionally). However, if you think the elective stuff is all you will probably have to deal with, go for it.

Generally, PPOs have more leeway from selecting doctors and slightly higher copays, but cover more overall when big stuff goes down. HMOs are generally cheaper on the copay, have more restricted doctors, and pay for less on large issues.

In eaither case, you get screwed. Read everything extremely closely. My experience has been with United and Aetna, others may and probably do vary.

Septus

Deebaser wrote: »

I personally had shitty experience with an old DMO, but the fee scheduiles don't necessarily have to be garbage. I'm also assuming the for ortho there is still at least a 20% coinsurance. It all boils down to, whether or not there is a competant provider in your area that accepts your coverage.

Well shit, the coinsurance thing sounded weird, so I checked it again. With the DMO I only pay the flat $2100 for orthodontistry performed by a general dentist, which is not something I'd ever want to do. For an orthodontist, I'd pay 75% of full cost, however the providers are still very limited.

I think I'll go ahead and shell out the extra $1500-2000 for seeing this better guy, rather than going somewhere else for what I thought was a $4600 difference.

Deebaser

K, also be sure to look at the annual max. In my experience dental caps out under $2000 per year. If the good dentist is able to break down the procedures over multiple calendar years, you are money.

Septus

Deebaser wrote: »

K, also be sure to look at the annual max. In my experience dental caps out under $2000 per year. If the good dentist is able to break down the procedures over multiple calendar years, you are money.

Yeah, I did that with some other procedures. In this case though, I don't think it'd apply. The DMO plan has no annual cap, and the PPO plan gives no coverage for this at all.

Deebaser

Whoops my bad, I thought you were talking about the PPO ortho bene (even though I mentioned a single post earlier that a DMO probably has co-insurance on that).

Is this a medical PPO, because a dental PPO with no ortho benefit seems a little off to me. It's been years since Ive dealt with the industry but that is an odd thing to leave off the benefits schedule.

Septus

Dental. It has ortho coverage, but only for dependents.