Understanding your Orthodontic Insurance Coverage
Some dental insurance plans have orthodontic coverage that can help offset the overall cost of orthodontics. Below are some general points that can help you better understand your benefits.
In this article, you’ll learn:
- Eligibility & benefits
- Payments
- Starting date
- Mid-treatment insurance changes
- Work in progress
- Dual coverage
- In and out of network coverage
- Questions to ask when looking at orthodontic dental insurance coverage
Eligibility & benefits
When we see you or your child for your initial consultation, we will verify your eligibility and benefits by contacting your dental insurance provider. Ideally, we hope to determine if the plan has any orthodontic coverage, if it is active, how much coverage is available, and how the insurance will pay out benefits. Unfortunately, sometimes this information is not available to us and occasionally the information can be inaccurate. We recommend verifying your benefits directly with your dental insurance company or HR department to help make sure everything is clear.
Payments
Insurance companies can choose how to pay out their benefits, ranging from paying in full as soon as treatment starts, to yearly, quarterly, or monthly payments throughout treatment. If insurance does not pay in full at the start of treatment, insurance coverage needs to remain active for the duration of treatment to receive full benefits.
Starting date
The start date of treatment is when appliances are placed in the mouth, not when the initial diagnostic records are collected. Insurance companies use this date to process the claim. If you are getting ready to start orthodontic treatment but are expecting a change in insurance, it’s best not to have appliances placed until you have confirmed your benefits are active, as some insurance plans will not provide coverage for treatment that began before the plan was effective.
Mid-treatment insurance changes
If your insurance benefits change or terminate, often due to job changes/loss, notify your provider immediately. You are responsible for any benefits not paid by your insurance.
Work in progress
If your insurance company or coverage changes mid-treatment, your status is considered “work-in-progress” with your new insurance. Every plan is different – some may offer coverage for treatment that is in progress while others will not.
Dual coverage
Dual coverage is when you are actively covered under two dental plans. Some plans allow for a coordination of benefits which allows benefits from both plans to be used. Other plans have a non-duplication clause, allowing only the primary plan to provide coverage.
In and out of network coverage
Some dental insurance plans offer different coverage for in and out-of-network providers. Ask your HR department or dental insurance company if coverage is different for in and out-of-network providers so you can determine if this will impact where you seek orthodontic treatment.
Questions to ask when looking at orthodontic dental insurance coverage
What are the lifetime maximum benefits?
Plans typically offer a lifetime benefit for orthodontics that will not renew annually like standard dental benefits.
What percentage of treatment is covered?
If your treatment plan costs $3000 and your insurance plan covers 50% up to a lifetime maximum of $2000, you will get $1500 of coverage ($3000 x 50% = $1500)
Is there an age limit on the plan?
Some plans exclude adults or will only cover children up to a certain age, while others have no age limits
Is there a waiting period to begin treatment?
Some plans require a 60 day/90 day/1 year waiting period before covering orthodontic benefits
The Takeaway
Because orthodontic insurance coverage works differently than standard dental or medical benefits, it can be difficult to understand how it applies to your treatment. At Garfinkle Orthodontics, we’re happy to help you through the process and answer your questions along the way.