Introduction
Orthodontic benefits refer to the coverage provided by dental insurance plans for orthodontic treatment, such as braces or Invisalign. Many dental insurance policies include at least some level of orthodontic benefits, which help offset the cost of orthodontia for policyholders. Understanding what orthodontic benefits you have can help you budget for braces or aligners and get the smile you want.
Types of Orthodontic Benefits
There are a few main types of orthodontic benefits to be aware of:
Comprehensive Orthodontic Benefits
Comprehensive orthodontic coverage provides the highest level of benefits, covering a set portion of the total cost of treatment. This may be 50% to 80% of the total fees.
Limited Orthodontic Benefits
Limited orthodontic benefits cover a smaller percentage of the total treatment cost, usually around $1,000-$1,500 total per person.
Lifetime Maximum Benefits
Some dental plans set a lifetime maximum dollar amount they will contribute toward orthodontic treatment per person, such as $2,000. Once this max is reached, the patient must pay the remainder of the fees.
Factors That Affect Orthodontic Benefits
Several factors determine the orthodontic benefits you receive:
Type of Dental Plan
- PPO plans often have the best orthodontic benefits
- DHMO plans may include limited orthodontic coverage
- Discount dental plans provide discounted rates but no actual benefits
Your Specific Policy
Orthodontic benefits can vary widely, even within the same type of dental plan. It’s important to read your specific policy to see what orthodontic services are covered and what percentage of fees are paid.
Use of In-Network Providers
Using orthodontists in your dental insurance network will ensure you receive the highest level of benefits. Out-of-network fees may not be covered at all or have higher deductibles.
Waiting Periods
Many dental policies require 6-12 months of continuous coverage under the plan before orthodontic benefits activate. This prevents people from signing up just to receive braces coverage.
What Orthodontic Services are Typically Covered?
Orthodontic benefits often cover a portion of the following services:
- Braces – metal, ceramic, lingual braces
- Removable clear aligners like Invisalign
- Retainers
- Extraction of teeth to prepare for orthodontic treatment
- Orthodontic records – x-rays, molds, photographs
However, other orthodontic services may be limited or excluded, such as:
- Orthognathic surgery
- Temporary anchorage devices
- Accelerated treatment programs
- Replacement of lost orthodontic appliances
What Out-of-Pocket Costs are Typical?
Even with orthodontic benefits, some out-of-pocket expenses are to be expected. These may include:
- Deductible – Plans often have a $50-$150 deductible for orthodontic treatment you must meet first before benefits kick in.
- Coinsurance – Many policies cover a set percentage of fees, leaving you to pay a coinsurance amount (e.g. you pay 20% of the fees).
- Maximums – If your plan has an annual or lifetime maximum dollar amount they cover, you’ll be responsible for costs above that.
- Non-covered services – Any orthodontic services not included in your policy will be your responsibility.
You’ll want to factor in potential out-of-pocket orthodontic costs as you evaluate plans and insurance estimates.
Estimating Your Orthodontic Benefits
To get an accurate picture of what orthodontic benefits you can expect with insurance:
- Have your orthodontist submit a pretreatment estimate to your dental plan.
- The plan will provide an estimate of your total fees, what is covered, and your estimated out-of-pocket responsibility.
- This helps you budget for orthodontic treatment and understand your insurance coverage.
Be sure to get this pretreatment estimate in writing from your dental plan and orthodontist before starting treatment.
Maximizing Dental Insurance Benefits for Braces
To make the most of your orthodontic benefits, consider these tips:
- Review multiple dental plan options and compare orthodontic benefits before choosing a policy.
- Select an in-network orthodontist to maximize covered services.
- Start orthodontic treatment once any waiting periods have passed.
- Pay attention to annual maximums – timing extractions or starting treatment in a different calendar year can sometimes maximize benefit usage.
- Enroll dependent children early to take advantage of child and teenage orthodontic benefits.
- Use tax-advantaged accounts like FSAs or HSAs to save for orthodontic costs.
Careful planning can help you prepare for orthodontic expenses even with insurance coverage.
Providing Proof of Orthodontic Benefits to Your Provider
Your orthodontist’s office will want proof of your benefits before starting treatment. Be prepared to provide:
- Your dental insurance ID card
- A printed copy of your policy’s orthodontic benefit summary
- The pretreatment estimate from your insurance plan
Having this information readily available will allow the dental office to accurately calculate your expected out-of-pocket costs and file claims correctly on your behalf.
Appealing Denied Orthodontic Insurance Claims
If your dental plan denies coverage for part of your orthodontic treatment, you have the right to appeal the decision. Follow these steps:
- Contact your insurer and request the specific reason for the denied claim. Get this in writing.
- Ask your orthodontist to draft a letter explaining why the treatment is medically necessary.
- Submit the letter from your orthodontist and any other supporting documentation to your insurance company to request a review of the denied claim.
- If the plan upholds their decision, examine your policy and assess whether it may be worth challenging through an external appeals process or complaint to your state’s insurance regulatory agency.
Document everything in writing throughout the appeals process. Be persistent yet professional in challenging any erroneous denials.
Key Takeaways on Orthodontic Benefits
Here are some main points to remember about orthodontic insurance coverage:
- Orthodontic benefits help offset the costs of braces and aligners, but don’t typically cover the full amount.
- Benefits can vary greatly between different dental insurance plans.
- Carefully read your policy details to understand which services are covered and your expected costs.
- Get a pretreatment estimate from your insurer to determine your estimated insurance contribution and out-of-pocket expenses.
- Consider supplemental plans or savings accounts in addition to insurance to prepare for orthodontic treatment costs.
Understanding your orthodontic benefits early on makes it easier to plan for and budget for braces or Invisalign. With some careful preparation, you can feel confident pursuing the smile you’ve always wanted even with high out-of-pocket orthodontic costs.
Conclusion
Orthodontic insurance coverage can be a big help in affording braces or Invisalign treatment. While rarely covering the full cost, orthodontic benefits take a chunk out of the fees to make aligners or braces more budget-friendly. Taking the time to understand your specific dental policy, get accurate estimates, and maximize your available benefits goes a long way in preparing for orthodontic expenses. With some savvy planning, you can feel good taking advantage of the orthodontic insurance you have access to and get the smile you deserve.