October 21, 2024
SecureCare offers The Copay Plan MAC and does not provide DHMOs, like EDS; however, our team regularly receives questions about the difference in the two types of plans.
To help answer these questions here is a brief overview to explain the differences between The Copay Plan and a DHMO.
Quick Summary of the Plans:
The Copay Plan is comprehensive PPO MAC dental insurance with a schedule of member copays.
A DHMO, such as EDS, is more like a discount dental plan with a set of member copays.
How do you explain the difference in the plans?
The Copay Plan and DHMO are very different types of dental plans and cannot be considered in the same plan category.
The Copay Plan is a PPO (MAC) insurance plan with the fully-insured features expected in a dental insurance plan.
DHMOs on the other hand are not insurance at all and have their own separate category similar to a discount plan.
The Copay Plan (MAC)
SecureCare offers The Copay Plan and does not offer DHMOs. The Copay Plan is a PPO (MAC) dental insurance plan.
As a PPO (MAC) insurance plan, The Copay Plan has a large contracted provider network with no balance billing. Non-contracted or out-of-network dentists are paid according to a fixed reimbursement fee schedule or a Maximum Allowable Charge (MAC).
Here are some features of The Copay Plan:
The Copay Plan has a national provider network with nearly 300,000 provider access points. Members are in-network in all 50 states.
The Copay Plan automatically includes SecureCare's Mexico Dental Network, allowing members to receive in-network coverage all along the border from credentialed, contracted providers in Mexico.
The Copay Plan is a fully-insured PPO MAC with no annual maximum.
Because The Copay Plan is dental insurance, actual claims payments are made to dentists for services performed.
Since The Copay Plan is a PPO dental insurance plan, it covers the full American Dental Association list of procedure codes you would expect from a comprehensive PPO dental insurance plan.
Members do not have to choose a dentist and family members may go to different dentists.
One Plan Change Benefit: Where a group client is offering both The Copay Plan and one or two PPO Plans, a member may change plans once a calendar year, off-renewal, with no qualifying event. Members on a PPO Plan may change to The Copay Plan to finish services, for example, if they meet their annual maximum. The members changing plans will be effective the first of the following month. Members may also change from The Copay Plan to a PPO Plan.
The Copay Plan Features Recap
Access to the large SecureCare US-Mexico provider network
Members pays fixed copays and providers submit claims to SecureCare, so providers receive payments when they perform services.
No calendar year annual maximum benefit limit
Insured General Dentist and Specialist coverage; not just a discount
Direct access to specialists without needing a referral
No extra labe fees: Cost of laboratory fees for services such as crowns, implants, partials, bridges, dentures, etc... included in member copay
Contracted providers will schedule new patient appointments
Members may switch dentists without notifying plan
Family members may visit different contracted providers.
There is no roster a member must be on to be seen in a dental office.
Now Let's Take a Look at DHMO Dental Plans
A DHMO or Dental Health Maintenance Organization, such as EDS, typically refers to a more restrictive, discount type dental plan usually with a much smaller network or group of contracted providers than a PPO like The Copay Plan. DHMOs may also be called prepaid plans because dentists receive a small prepaid fee each month "per head" for each member assigned to their office.
Typical features of a DHMO are:
Members receive a discount on dental services when they visit a DHMO provider.
Providers do not file a claim and the DHMO pays no claims. As a result, a DHMO is similar to a discount plan.
A DHMO plan generally covers fewer dental services than The Copay Plan, shifting more out-of-pocket costs to the member in the form of possible discounts.
DHMOs have a much more limited number of in-network providers than The Copay Plan.
DHMOs do not include out-of-state benefits
DHMOs do not include a Mexico Dental Network
DHMO providers do not receive payment from the DHMO plan for each service they perform for a member. Providers receive a very small dollar amount each month for each member assigned to their office. This payment is called capitation.
Unlike The Copay Plan, DHMO members must be “assigned” to a DHMO provider prior to receiving services from the provider. The DHMO plan must approve a member's request to change providers.
There is often no Specialist care coverage with a DHMO. Specialist services are generally just discounted off usual fees.
Typical DHMO Recap:
Small local provider network; no national network; no out-of-network
Like a discount plan. DHMOs do not pay claims
Specialists services usually just a discount - No insured coverage
Referral sometimes needed for Specialist services
Discounted orthodontic services only
Cost of laboratory fees (ie. crowns, implants, partials, bridges) billed extra on top of procedure copay
Contracted DHMO providers may close to new patient appointments, not allowing any new DHMO patients to schedule appointments with their office.
DHMO must approve a member provider change before a member can see a different dental provider.
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