Does dental insurance cover orthodontics? How to use your insurance for orthodontic care
October 12, 2023
Whether orthodontic treatment is covered by dental insurance largely depends on the specifics of your insurance plan. Some plans offer comprehensive coverage for orthodontics, while others may only cover a portion of the costs, or exclude orthodontic coverage entirely. If you’re wondering whether your dental plan covers orthodontics, your insurance provider can offer detailed information. However, you should be aware of a few things before starting any orthodontic treatment.
Here are some key factors to keep in mind:
- Type of Insurance: Employer-sponsored dental insurance plans and private dental insurance plans often offer some form of coverage for orthodontic treatment. Medicaid offers orthodontic coverage also covers orthodontics for individuals under the age of 21 in many states.
- Age Limitations: Some It’s common for some insurance plans to offer orthodontic coverage only for beneficiaries under a certain age, typically 18 or 21. However, some plans also offer coverage for adult orthodontics.
- Coverage Amount: Insurance plans that cover orthodontics often have a lifetime maximum benefit for these services, which might not cover the full cost of treatment.
- Waiting Periods: Some insurance policies require a waiting period before you can claim orthodontic insurance benefits for your orthodontic treatment. This means you a patient would need to be enrolled in the plan for a certain amount of time before the coverage applies.
- Medically Necessary Orthodontics: In some cases, orthodontic treatment is deemed medically necessary, such as when severe malocclusion interferes with oral functions like eating or speaking. Some insurance plans may offer more comprehensive coverage for medically necessary orthodontics.
- In-Network Providers: Insurance companies typically have a network of providers with whom they've negotiated discounted rates. Your costs will generally be lower if you choose an in-network orthodontist for your insurance needs.
Before starting orthodontic treatment, it's important to check with your insurance company to understand what your plan covers. Ask about any age restrictions, lifetime maximums, waiting periods, and what portion of the treatment cost you'll be expected to pay out-of-pocket. If you’re wondering about your orthodontic dental coverage, your Your orthodontist's office can also work with you and help you understand your insurance coverage and out-of-pocket costs.
Are out-of-network orthodontists covered by dental insurance?
Whether an out-of-network orthodontist is covered by your dental insurance will also depend on the type of insurance plan you have.
If you have a Preferred Provider Organization (PPO) dental insurance plan, it generally allows for some level of coverage for out-of-network providers. However, your out-of-pocket costs will typically be higher than if you choose an orthodontist who is in-network. This is because insurance companies negotiate lower rates with their in-network providers. Additionally, out-of-network orthodontists might charge more than the amount your insurance company is willing to pay, and you could be responsible for paying the difference.
On the other hand, if you have a Dental Health Maintenance Organization (DHMO) plan, out-of-network care is typically not covered unless it's a true emergency. If you choose to see an out-of-network orthodontist under such a plan, you'll likely be responsible for the full cost of treatment.
It's important to note that every dental insurance plan is different. Some may offer no coverage for out-of-network care, while others may cover a portion of the cost. It's crucial to check your specific plan details or reach out to your insurance company to understand your coverage before receiving treatment from an out-of-network orthodontist. Your orthodontist's office may also be able to help you understand your insurance coverage.
In short, navigating the intricate world of insurance policies can sometimes be daunting, especially for specialized services like orthodontic care. Understanding the nuances between in-network and out-of-network providers might not be common knowledge for the average individual. Based on industry insights, many patients might seek additional clarity on these topics. The decision-making process might seem even more complex when considering other potential dental needs. That's why it's crucial to complete a thorough assessment of your insurance plan, ensuring that you're well-informed about all the benefits you're entitled to. By being proactive and understanding your coverage, you can make informed decisions that best suit your orthodontic needs and financial situation.
If you decide to see an out-of-network orthodontist, SuperBill for insurance can help! We file out-of-network claims on your behalf, and we follow up with your insurer to make sure you get the best reimbursement possible.
Do orthodontists take insurance even when they are not part of any network?
An orthodontist can accept insurance even if they are not part of the insurance network, but how the insurance pays out and what your costs will be can depend on the specifics of your insurance plan and the policies of the orthodontist's office.
As we mentioned before, if you have a Preferred Provider Organization (PPO) plan, it generally provides some level of coverage for out-of-network services. However, even if your insurance provides out-of-network orthodontic insurance benefits, not all orthodontists will accept all types of insurance. It's also important to note that when a provider is out-of-network, they may bill you for the difference between what your insurance company will pay and what they charge, a practice known as balance billing. This is in contrast to in-network providers, who agree to accept the insurance company's negotiated rates for services.
If you have a Dental Health Maintenance Organization (DHMO) or Exclusive Provider Organization (EPO) plan, these typically do not cover out-of-network care, except in emergency situations.
Before beginning orthodontic treatment, it's important to discuss your dental insurance and orthodontics coverage insurance with both your insurance provider and the orthodontist's office. They can provide the most accurate information about what costs you might be responsible for and what your dental insurance with orthodontic care will cover.
Does dental insurance cover orthodontics differently depending on your plan?
Yes, dental insurance coverage for orthodontic treatment can vary greatly depending on the specifics of your insurance plan. Here are some of the ways in which coverage can differ:
- Type of Plan: There are various types of dental insurance plans, such as Dental Health Maintenance Organization (DHMO) plans, Preferred Provider Organization (PPO) plans, and Dental Indemnity plans. Each of these has a different structure for coverage, which can affect what is covered and how much is paid.
- Level of Coverage: Some insurance plans provide comprehensive orthodontic coverage, while others may cover only a portion of the costs, or exclude orthodontic insurance coverage entirely.
- Age Restrictions: Many insurance plans offer orthodontic coverage only for beneficiaries under a certain age, typically 18 or 21. However, some plans do provide coverage for adult orthodontics.
- Lifetime Maximum: Insurance plans that do cover orthodontics often have a lifetime maximum amount that they will pay towards orthodontic treatment. Once this maximum has been reached, the remaining costs will be out-of-pocket.
- Waiting Periods: Some dental insurance policies require a waiting period before you can claim benefits for orthodontic treatment. This means that you must be enrolled in the insurance plan for a certain period before you can receive coverage for orthodontics.
- In-Network vs. Out-of-Network Providers: If your orthodontist is in-network, they have a contract with your insurance company to provide services at a reduced rate, which can lower your out-of-pocket costs. If your orthodontist is out-of-network, your plan may not cover the cost, or it may cover less, making your out-of-pocket costs higher.
Before starting orthodontic treatment, it's important to check with your insurance provider to understand what your plan covers. This can help you avoid unexpected costs and ensure you're getting the most out of your insurance benefits.
How to find orthodontics covered by dental insurance
Finding orthodontic services that are covered by your dental insurance involves several steps:
- Understand Your Coverage: Start by reviewing your dental insurance policy. Check whether orthodontics is covered and under what conditions. Be aware of any age restrictions, waiting periods, lifetime maximums, or other limitations. If you have difficulty understanding your policy, contact your insurance company directly for clarification.
- In-Network Orthodontists: Most insurance plans have a list of in-network providers that they have agreements with. Using an in-network orthodontist typically results in lower out-of-pocket costs. You can find a list of in-network orthodontists on your insurance company's website or by calling their customer service line.
- Confirm Coverage: Once you have selected an in-network orthodontist, it's a good idea to confirm coverage. You can do this by calling your insurance company or asking the orthodontist's office to verify your benefits. Make sure to ask about any copayments, coinsurance, or deductibles you will be responsible for.
- Get Preauthorization if Required: Some insurance companies require preauthorization for orthodontic treatment. This means your orthodontist will need to submit a treatment plan to the insurance company for approval before treatment begins.
- Consider a Consultation: Most orthodontists offer a free or low-cost initial consultation. This appointment can give you an idea of what treatment will involve, what it will cost, and how much your insurance will cover.
Remember, every insurance plan is different, and what is covered can vary greatly. It's important to do your homework to understand your coverage and avoid unexpected costs.
What to do if you can’t afford orthodontic care
If you're struggling to afford orthodontic care, there are several options you might consider to help reduce costs or make payments more manageable:
- Payment Plans: Many orthodontists offer payment plans, allowing you to spread the cost of treatment over an extended period. This can make treatment more affordable by breaking down the overall cost into manageable monthly payments.
- Dental Schools: Dental schools often offer orthodontic treatment at a reduced cost. Treatment is provided by students under the close supervision of experienced faculty. While the process might take longer due to educational purposes, it's a viable option if cost is a major concern.
- Discount Dental Plans: Unlike traditional dental insurance, discount dental plans require you to pay an annual fee in exchange for significant discounts on dental services, which can include orthodontic treatment.
- Nonprofit Organizations: Some organizations, like Smiles Change Lives or the American Association of Orthodontists' Donated Orthodontic Services program, offer low-cost or even free orthodontic treatment for individuals who qualify.
- Government Programs: Children, teenagers, and some adults might be eligible for government assistance programs like Medicaid or the Children's Health Insurance Program (CHIP), which often cover orthodontic treatments.
- Negotiate Prices: Don't hesitate to discuss pricing with your orthodontist. In some cases, they may be willing to negotiate the cost of treatment or offer a discount for upfront payment.
- Consider Less Expensive Treatment Options: There may be less expensive alternatives to traditional braces, such as clear aligners. Discuss your options with your orthodontist.
- Flexible Spending Account (FSA) or Health Savings Account (HSA): If you have a FSA or HSA, you can use these pre-tax dollars to pay for orthodontic treatment.
Remember, it's essential to discuss your financial concerns with your orthodontist or their billing department. They may be able to offer solutions or suggest resources to help you afford your orthodontic care.
How SuperBill helps with orthodontics reimbursements
If you do have out-of-network dental benefits, and are considering dental insurance that covers orthodontics but need clarification about your coverage, or you’re unsure if your dental insurance covers orthodontics, SuperBill may be able to help! SuperBill verifies your benefits, then files and tracks your out-of-network claims. We will update you on the status of your claim at every interval, and do everything we can to get it reimbursed. We even help with medical bill negotiation!
You can jump through all the hoops to make sure you get your orthodontic care covered by insurance, OR you can let SuperBill for insurance handle it all for you. We have worked with countless patients to get them the reimbursement they deserve.