Aetna dental plans: DMO and PPO explained

Aetna's dental coverage through an employer comes in two designs, and the choice matters more than the brand name. The DMO, short for dental maintenance organization, asks you to pick a primary care dentist from its network and see that office for exams and referrals. Aetna says there is no deductible, no claim form and no yearly dollar limit. The PPO lets you see any licensed dentist without choosing a primary one, with lower costs when the dentist is in the network, and it does carry deductibles and yearly dollar limits. Aetna describes DMO premiums as generally lower and PPO premiums as generally higher. Your employer decides which of these you are offered, and your costs depend on the specific plan chosen. Ask which plan type your employer actually bought, because a DMO and a PPO from the same company can pay the same procedure very differently.

Before you book: verify aetna dental plans

1
Ask your employer which Aetna dental plans are offered
2
Use the provider search to check whether your dentist joined the DMO, the PPO or both
3
Read the benefits summary for copays and coinsurance before the visit
4
Ask a network dentist to file the claim for you
5
Request a written estimate before major work

Two designs

How the Aetna DMO and PPO differ

Factor	Detail
Primary dentist	The DMO needs one, chosen from the network. The PPO does not ask you to choose a primary care dentist.
Network size	The PPO gives you a larger network to choose from, according to Aetna. The DMO limits you to its own network.
Deductible and yearly limit	Aetna lists none for the DMO. It lists both for the PPO.
Specialists	The DMO needs a referral for a specialist, except for orthodontists. The PPO does not need a referral.
Premiums	Generally lower with the DMO and generally higher with the PPO, in Aetna's words.
Lifetime limit on major services	Aetna says the DMO has no lifetime limit for major services. It does not make the same statement for the PPO.

Aetna's page says your specific costs and features depend on the plan you choose, and that dental benefits contain exclusions and limitations.

The DMO in practice

What using a DMO looks like

Pick a primary care dentist from the network and give the office your member information at each visit
Covered family members can each pick their own primary care dentist
See that dentist for regular exams and to get referrals when specialty care is needed
Pay your share at the visit, which is either a copay (a set dollar amount) or coinsurance (a percentage of the dentist's charge)
If you want to change dentists, do it on the member website by the 15th of the month, and the change starts on the first day of the next month

Aetna warns that seeing someone other than the dentist you chose could cost you more. Read the benefits summary first.

The PPO in practice

Network and out-of-network under the PPO

Factor	Detail
In network	Aetna says there is no paperwork and costs are lower. Network dentists offer special rates for covered services and file the claims for you.
Out of network	You may see any licensed dentist. Aetna says you may pay more and may have to file your own claims.
Virtual dentistry	PPO members can use virtual visits for routine evaluations, second opinions, referrals and prescriptions. Aetna names Dental.com and TheTeleDentists in its network.
New York cost estimates	Aetna's page says dental consumers in New York can use an online estimate of services.

Choosing between them

When each design tends to fit

Aetna's own guide sets out the trade. It suggests a DMO if your dentist is in the network, if you expect major dental services, or if cost is your main concern. It suggests a PPO if being able to see any dentist matters most, or if you want to see a specialist without a referral. Neither choice is right in general. The useful test is concrete: search the provider directory for your own dentist under each plan design before you enroll, and ask your employer for the benefits summary of each.

The provider directory is the only reliable way to learn whether a specific office joined the DMO, the PPO, both or neither.

Where people get caught

Common surprises with an Aetna dental plan

Assuming an office that takes Aetna joined both the DMO and the PPO. Check the network for the plan you actually hold.

Seeing a DMO dentist other than the one you selected and finding the cost higher

Needing a specialist under the DMO and skipping the referral step

Forgetting that PPO deductibles and yearly dollar limits exist, and treating a large plan as if it had no ceiling

Going out of network on the PPO without expecting to pay first and file the claim yourself

Questions people ask

Common questions

What is the difference between an Aetna DMO and an Aetna PPO?

The DMO makes you choose a primary care dentist from its network and pay a copay or coinsurance at the visit, with no deductible and no yearly dollar limit. The PPO lets you see any licensed dentist without a primary one, and it has deductibles and yearly dollar limits. Aetna says premiums are generally lower for the DMO and higher for the PPO. Which fits you depends on whether your dentist is in the network.

Do I need a primary care dentist with Aetna dental?

Under the DMO, yes. You select one from the network, and that office guides your care and gives referrals. Covered family members can pick different primary dentists. Under the PPO you do not need one at all. If you belong to a DMO and see a different dentist, Aetna warns you could pay more.

Does the Aetna DMO have an annual maximum?

Aetna states that the DMO has no yearly dollar limits and no deductible. It also says the DMO has no lifetime limit for major services. That is a statement about the design. Your copays and coinsurance still apply to each service, and your benefits summary lists them, so read it before you commit to a large treatment plan.

Does the Aetna PPO have deductibles and yearly limits?

Yes. Aetna's comparison lists deductibles and yearly dollar limits for the PPO and none for the DMO. The amounts depend on the plan your employer chose. Ask for the benefits summary to see the deductible, the yearly limit and how much of the limit you have already used this year.

Can I see a specialist without a referral?

With the PPO, Aetna says no referral is needed for specialists. With the DMO a referral is needed, except for orthodontists. If you expect to need an oral surgeon, endodontist or periodontist, that difference is worth weighing before open enrollment, because the referral step adds a visit to your primary dentist first.

What happens if I go out of network with the Aetna PPO?

You can see any licensed dentist, but Aetna says you may pay more and may have to file your own claims. The page does not say how much more, so the plan documents decide. Ask the office for a written estimate, ask the plan what it would pay for that office, and compare the two before you book.

Who files the claim under the Aetna PPO?

Aetna says network dentists file claims for you, so there is no paperwork when you stay in the network. Out of network, you may have to file your own. Under the DMO, Aetna says there are no claim forms at all. Either way, check the explanation of benefits after each visit to see what was paid.

How do I change my DMO dentist?

Use your member website. Aetna says you can change your primary care dentist once a month, and that you should switch by the 15th day of the current month. The change then starts on the first day of the next month. Each covered family member can change their own dentist separately.

Are virtual dental visits included?

Aetna says PPO members can use virtual dentistry for routine evaluations, second opinions, referrals and prescriptions, and names Dental.com and TheTeleDentists in its network of virtual providers. A virtual visit does not replace an exam for pain or swelling. If a problem needs hands-on care, you still go to an office.

Which Aetna dental plans can I choose?

That is up to your employer. Aetna's page tells you to ask your employer which plans are available, and it says your specific costs and features depend on the plan chosen. Two coworkers can hold different Aetna dental plans, so use your own benefits summary and not a friend's description.

Is there a cost estimator for Aetna dental?

For dental consumers in New York, Aetna's page points to an online cost estimate of services. It does not describe the tool for other states. Members everywhere can look up covered services and check claims through the member website or the app, and any dentist can request a written estimate before major treatment.

Can family members choose different dentists on the Aetna DMO?

Yes. Aetna says covered family members can each choose their own primary care dentist from the network. Each person's dentist guides that person's care and gives referrals, and each can change dentists on the member website following the once-a-month rule. Check the provider search to confirm that every dentist you want is in the DMO network.