Billing · Updated 2026-09-08 · 5 min read
How does a dental HMO like DeltaCare USA pay the office?
A capitated plan pays a fixed monthly amount per assigned member whether or not they come in, and the patient's copay is payment in full.
A dental health maintenance organization plan pays your office in two parts and neither of them is a fee for the procedure. The first is capitation: a fixed amount each month for every member assigned to your office, paid whether or not that member walks in. The second is the patient's copay, taken from the plan's copay schedule at the time of service, which a participating provider accepts as payment in full. On the DHMO products in this article there is no annual maximum and no deductible, and care from any dentist other than the member's assigned provider is not covered, except for out-of-area emergency treatment. Copay amounts are set per plan, so there is no carrier-wide table to quote and we will not print one as if there were. Kaylie has not measured capitation rates or copays; what follows is what the carriers' own documents say.
What the carriers' own documents say
The clearest plain-English description of capitation in any of the sources:
"General dentists are paid on a capitated basis, which is a specific fixed amount for each covered person or family every month, whether or not services are provided in a given month… Plans with lower monthly capitation fees will have higher patient copayments and plans with higher monthly capitation fees will have lower relative patient copayments."
— Delta Dental of New Jersey 2023 Participating Dentist Handbook, Chapter 14, describing its New Jersey-licensed DHMO. That second sentence is the trade the employer is making: the capitation rate and the copay schedule move in opposite directions, and both are set before your office sees a single patient.
On billing the patient, the rule is absolute:
"For DeltaCare® USA, participating providers agree to accept the member's copayment as payment in full."
— Delta Dental, "Protect your patients beyond the chair: Avoid balance billing issues", FYI, April 23 2026. There is no gap to bill on a covered service. The same article reminds providers that inclusive services — "anesthesia, routine post-operative care, or components of a comprehensive procedure" — are already inside the allowed amount and billing them separately overcharges the patient.
How the plan is sold to the member:
"With DeltaCare® USA, a DHMO-type plan, members must see a dentist in the DeltaCare USA network. At the time of service, they pay only the copayments listed in their plan documents for services received, making dental care more predictable and affordable. All plans cover emergency out-of-network care for stabilization or palliative relief."
— Delta Dental Insider Update, January 23 2026. And from a member-facing explainer: "No deductibles or maximums. Members can get as much care as they need without worrying about running out of coverage" — Delta Dental, "DeltaCare® USA: The basics", Insider Update, February 17 2023.
Reading across Delta's federation-wide policy documents, DeltaCare USA is a prepaid plan with an assigned contract dentist, set per-procedure copays by CDT code, no annual maximum, no deductible and no waiting periods, with out-of-network care not covered except an out-of-area emergency — typically capped around $100 per enrollee, with no cap in Texas. It is administered nationally from Alpharetta, Georgia whichever Delta company underwrites it, and the pediatric-dentist age limit rose from 7 to 13 across the federation effective February 2024. That is a summary of the documents rather than a single Delta sentence.
Cigna's DHMO, Cigna Dental Care, works the same way with different vocabulary: a contracted network general dentist, referrals for specialty care, a Patient Charge Schedule of per-code copays, no annual maximum, no deductible, and no out-of-network coverage except emergencies. United Concordia's Concordia Plus is a closed panel with an assigned primary dental office and the same structure, with one billing exception worth knowing: on Concordia Plus plan documents an in-network provider may charge an additional $125 for precious or semi-precious metal beyond the listed copay.
Why it depends on the plan
The copay schedule is a plan document, not a carrier document. Neither Delta nor Cigna publishes a carrier-wide dental copay table, and any figure you have seen quoted as "the DHMO copay for a crown" came from one employer's plan. The only reliable copay is the one on the patient's own plan documents.
The capitation rate is also per contract, and it is what makes a DHMO a different business decision from a PPO rather than a worse fee schedule. Your revenue on a capitated panel is a function of how many members are assigned to you and how often they come in, not of what you produce. A panel that never appears is capitation with no chair time; a panel that appears constantly is chair time at the copay.
One thing the DHMO removes entirely is the balance question that dominates the rest of this cluster. On a covered service there is no gap between an allowance and a fee for anyone to owe — the copay is the price, plus any material surcharge the schedule prints, such as the precious-metal charge above. What replaces it is the referral and assignment rule: treat a DeltaCare patient who has not selected your office, or perform specialty care without the referral from the patient's assigned dentist, and the plan pays nothing at all.
What to do
- Load the patient's own copay schedule, per plan and per CDT code. There is no carrier-wide list and estimating from another plan's copays will be wrong.
- Confirm the patient is assigned to your office before treating. Assignment, not eligibility, is what triggers payment on a DHMO.
- Get the specialty referral from the patient's assigned dentist before you treat. Delta describes specialty care on a DeltaCare USA plan as referred and coordinated by the member's own primary dentist, and care the plan has not arranged is not covered.
- Bill nothing above the copay on a covered service, including bundled components. Participating providers accept the copay as payment in full.
- Know what your capitation actually covers before you sign. The capitation rate and the copay schedule are set against each other, and a low-copay plan is a low-capitation plan for someone.
- Track the assigned panel size, not just production. It is the only number that predicts the capitation side of the revenue.
Numbers last refreshed August 2026.