Understanding your Orthodontic Benefits

At various times of the year many employers offer their annual open enrollment where employees have the option of changing, adding, or even dropping medical and dental coverage. Understanding orthodontic benefits can often times be a little bit trickier to figure out than regular dental and medical benefits. Here are a few tips to help you understand your coverage and a few questions you may want to ask when considering changing or adding dental plans as it relates to Orthodontic Coverage.

1. Just because you have Dental insurance does not mean you have orthodontic coverage.

Be sure to ask your plan if they cover both. Also, be sure to ask if the coverage is for adults and children or just children.

2. Orthodontic coverage typically involves a Lifetime Maximum (LTM) Benefit that pays out at 50% of the total case fee.

There are a few plans that pay more or less than 50% which means that they will pay for braces 1 time and once you have used all the LTM they won’t pay any more. If your LTM benefit is $2500, then braces would have to cost $5000 or more for you to use your full benefit. If treatment is below your LTM then the Insurance Company will only pay 50% of treatment.

3. Orthodontic benefits pay out over the course of treatment, not in one lump sum payment.

If your benefit is estimated at $2500, the Insurance Company generally pays you or the orthodontist an initial payment when the braces are placed and then monthly, quarterly, or annual installments for the remaining months of treatment. If the orthodontist estimates that you will be in braces for 2 years, then you would want to make sure you keep your dental plan during those 2 years. If you drop your dental/orthodontic insurance before your benefit has finished paying, this can result in more out of pocket expenses for you. If your dental insurance changes during the course of treatment, make sure the new insurance company takes “work in progress”.

4. Does your plan have a waiting period for orthodontic coverage?

Some dental plans require a waiting period before they will pay for braces. They might cover cleaning and general dentistry immediately, but sometimes will have you wait before orthodontic coverage is active. Be sure to ask your dental plan if there is a waiting period for braces.

5. Does your plan have an age limit?

Some plans have a minimum and maximum age for orthodontics. This means you either cannot start treatment until the minimum age is met, or you must start treatment before the maximum age. Ex. If the maximum age is 19, you must start treatment before turning 19 and your benefit might decrease if you are turning 19 during the course of treatment.

6. Can I have dual coverage for braces?

The answer is yes in most cases, but there are a few rules insurance companies follow when determining primary vs. secondary and you want to make sure your plan allows for standard coordination of benefits. The birthday rule determines whose plan is primary and looks at what month that person is born in. For example if mom’s birthday is 2/14/73 and dad’s birthday is 11/20/1968, mom’s plan, in most cases, would be considered the primary insurance plan because her birthday falls first in the calendar year. Overall age or who is older does not generally determine who is primary. Be sure to ask if your plan allows for standard coordination of benefits or has a non-duplicating clause. A non-duplicating clause means benefits will not be duplicated. So if both plans have a LTM of $1500 then with a no duplicating clause your total benefit is $1500. When coordination of benefits is allowed your benefit could be as high as $3000 if the LTM for both plans is $1500.

7. What happens if you get Orthodontic Coverage after you/your child has already started treatment?

Sometimes an employer will increase their plan benefits or you might even change employers and find yourself with orthodontic benefits that you did not have when you or your child first started treatment. The question to ask your new plan is if they cover “work in progress”, if they do, then generally your benefit is pro-rated based on the time you have been in treatment, and the time you have left in treatment.

8. Is your insurance out of network?

We are not providers for all insurance plans. Make sure to verify that you are able to go out of network and that your benefit is not affected by this. We consider these insurance plans “self file.” We will provide you with all of the necessary paperwork to provide to your insurance. Your insurance company will then make payments directly to you if you are eligible.