Orthodontics Coverage with MetLife: HMO vs PPO

Orthodontics are expensive! While there are more affordable options, like Invisalign, they still can cost a lot and usually have monthly payments. But by getting dental insurance, you’ll have coverage for those orthodontics, often making them much more affordable.  

SDPEBA offers two forms of dental insurance both managed by MetLife. An HMO plan and a PPO plan. Each plan differs rather drastically, but what’s the difference?  

Cost and Coverage 

The most obvious difference is the cost. The MetLife HMO plan offers a lower monthly premium than the PPO plan. But, as expected, that means that the HMO plan covers less than the PPO plan. 

With the HMO plan, you need to go to an in-network dentist and the coverage varies. You’ll owe a copay that can range between $725-1,450, but that covers up to 24 months of treatment. Additionally, you’ll owe a copay of $250 for each orthodontic appointment that concerns treatment planning, x-rays, photos, or models. As well as a $25 copay per visit past the 24 months of treatment.  

It’s important to note that the HMO plan covers very specific procedures as outlined in the summary of benefits. Certain types of orthodontics, such as Invisalign, are not covered under the Dental HMO plan. Please talk with your dental professional about what options your insurance covers prior to getting treatment.  

The PPO plan offers a 50% coinsurance, meaning you’ll pay 50% of what the orthodontist bills and your insurance will cover the other 50%. The PPO plan also has an orthodontics lifetime maximum of $2,000, which means they will not cover you past that amount. This means that if your braces are set to cost $4,500 then you will pay $2,500 and MetLife will pay $2,000. 

It’s important to note that MetLife’s “lifetime maximum” applies to all orthodontic procedures, even before you signed up for MetLife. That means this plan is best for individuals who have not had any orthodontics prior (Click here for the PPO plan brochure to learn more).  

The PPO plan also allows you to choose your own orthodontist, while the HMO plan requires you to go to an in-network provider. While you do have options with both plans, the PPO plan gives you more flexibility to shop around and find the best orthodontist for you.  

We highly recommend that you ask for a pre-treatment estimate before any dental procedure. It might slow down the process, but this way you will know how much you’ll be paying before the bill comes. 

As always, if you need help you can contact [email protected] or call 888-315-8027. We’ll gladly talk to you about your options and help you make the best decision for you.