What's the difference between an EPO and a PPO dental plan?

Who is this for?

Michigan Health Insurance – Customer Service – Dental Plans

Shopping for a dental plan, or a plan with dental and adult vision coverage? This explains how these plans work so you can choose the best one for you and your family.

Dental plans have some things in common with medical plans. They have deductibles, coinsurance and networks. In other ways they're different. For example, dental plans have an annual benefit maximum. Medical plans don't. If you understand how Blue Dental plans work, it'll be easier to choose a plan that fits your needs and budget.

If you need help with your group dental plan, talk to your employer.

Dental plan types

When you have a PPO medical plan, you get to choose the doctors you see. If a doctor you see is out of network, your plan still shares the cost. Blue Dental PPO plans work the same way:

  • You can see any licensed dentist and your plan will share the cost.
  • But you'll pay less when you see a dentist in our preferred PPO network. That's called getting your dental care in-network.

EPO stands for exclusive provider organization, and doesn't cover any out-of-network care. A Blue Dental EPO plan only covers services from in-network PPO dentists. This reduces costs, so your monthly payments will be lower.

The more a plan pays for out-of-network care, the higher your monthly payments will be. If you go out of network, you could be charged for the difference between what we pay and what your dentist charges. That's called balance billing.

If you want the freedom to see dentists outside our preferred network, a PPO plan could be best for you. Want to know if a dentist is in our network? See How do I find a dentist?

Choosing a dentist

Whether you choose a PPO or an EPO dental plan affects how much your monthly payment will be. Which dentist you choose determines how much you'll pay for services.

  • PPO in-network dentists You'll save the most when you see a PPO dentist who paricipates in our preferred network. Network discounts average 40%. Remember, EPO plans only cover services you get from dentists in this network.
  • Blue Par Select℠ dentists Although they're not part of our network, you'll still save if you see one of these dentists. EPO plans don't cover services from Blue Par Select dentists.
  • Out-of-network dentists You pay the dentist in full. Then you file a claim and we reimburse you for the share of the cost your dental plan covers. If the dentist charges more than we pay for a service, you’ll need to make up the difference. EPO plans don't cover services from out-of-network dentists.

Your out-of-pocket costs for dental care

When you get medical care, you and your plan share the cost, beginning with a deductible. That's the amount you pay for services before your plan begins to pay.

After you pay your deductible, you'll have coinsurance and copays. Your coinsurance is usually figured as a percentage of the amount we allow to be charged for services. A copay is a fixed amount you pay for a service, usually when you receive the service.

When you have a Blue Dental plan, there are no copays for dental care. Whether or not you have to pay a deductible depends on the plan and the kind of dental care you get. But deductibles are very low compared to medical plans. And you'll never pay a deductible for Class I preventive care like exams or cleanings.

Blue Dental plans do have coinsurance. Amounts vary from plan to plan. In general, the less you have to pay in coinsurance, the more your monthly payments will be.

You can see your out-of-pocket costs for dental care by looking on the benefits tab of our Blue Dental plans.

What's the difference between an out-of-pocket maximum and a benefit maximum?

An out-of-pocket maximum is the most you'll have to pay during a policy period, usually a year, for services you receive. Everything you pay for health care for everyone on the plan goes toward your out-of-pocket maximum. Once you reach your out-of-pocket maximum, your plan begins to pay 100 percent of the allowed amount.

Dental coverage works differently.

  • Only dental care for pediatric members has an out-of-pocket maximum, which only applies to services provided by PPO dentists. Pediatric members must be age 18 or younger when the plan starts.
  • Nonpediatric dental coverage for members who are age 19 and older has an annual benefit maximum. That's the most your plan will pay during a policy period, usually a year, for dental care each adult on the plan receives. Once you reach your benefit maximum, you pay 100 percent for dental care.

What about Blue Dental plans that include adult vision care?

Your network is VSP, one of the nation's largest providers of vision care. Although your plan will still share the cost if you get your vision care out of network from an eye doctor that doesn't take VSP, you'll pay more.

Unlike dental care, you'll have a copay for some services. But you won't have a deductible for vision care.