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Does Insurance Cover Braces? How to Use Your Insurance for Braces
For Patients

Does Insurance Cover Braces? How to Use Your Insurance for Braces

If you’re thinking about getting braces for yourself or a family member, you already know how expensive they can be. That’s why it’s crucial to get your braces covered by insurance, if possible. But when does insurance cover braces? And how do you choose the best insurance for braces?

This post will explain the ins and outs of using your insurance for orthodontic care. It may not be easy, but it’s worth the effort. Getting braces covered by insurance could save you thousands of dollars!

When are braces covered by insurance?

The coverage for braces by insurance can vary depending on the specific insurance plan and the individual's circumstances. In general, insurance coverage for braces is more common for children than for adults. Many insurance plans consider braces to be a part of orthodontic treatment, which is typically categorized as a form of dental care. Here are a few common scenarios where braces may be covered by insurance:

  1. Age limitations: Insurance plans often provide coverage for orthodontic treatment, including braces, for children under a certain age (usually up to 18 years old). However, coverage for adults may be limited or excluded altogether.
  2. Orthodontic coverage: Some insurance plans include orthodontic coverage as a part of their dental benefits. This may include coverage for braces or other orthodontic appliances. However, coverage may be subject to certain conditions, such as pre-authorization or a waiting period.
  3. Medical necessity: Insurance plans may provide coverage for braces if they are deemed medically necessary. This typically applies to cases where orthodontic treatment is required to correct significant functional or structural issues with the teeth or jaw.
  4. Supplemental insurance: Some individuals may have supplemental insurance plans that specifically cover orthodontic treatment, including braces. These plans may offer additional coverage or more flexible terms compared to regular dental insurance.

It's essential to review your specific insurance policy or consult with your insurance provider to determine the extent of coverage for braces, as it can vary significantly between plans and individuals.

Are out-of-network orthodontists covered by insurance?

The coverage for out-of-network orthodontists by insurance depends on the specific insurance plan and its policies regarding out-of-network providers. Here are some key points to consider:

  1. In-network vs. out-of-network: Insurance plans typically have a network of preferred providers, including orthodontists, with whom they have negotiated contracts and discounted rates. Visiting an in-network orthodontist often provides greater coverage and cost savings compared to an out-of-network provider.
  2. Out-of-network coverage: Some insurance plans may offer limited coverage for out-of-network orthodontists, but the benefits may be lower than those for in-network providers. This means that you might be responsible for a larger portion of the costs when choosing an out-of-network orthodontist.
  3. Higher costs: Visiting an out-of-network orthodontist may result in higher out-of-pocket expenses. Insurance plans typically have a predetermined fee schedule for covered services, and out-of-network providers may charge higher fees that exceed the plan's allowance. The patient would be responsible for paying the difference between the allowed amount and the orthodontist's charges.
  4. Reimbursement process: If your insurance plan offers out-of-network coverage, you may need to pay the full amount upfront and then submit a claim for reimbursement. The insurance company will evaluate the claim based on their out-of-network policies and reimburse you accordingly.

It's crucial to review the details of your insurance plan to understand its specific provisions regarding out-of-network orthodontists. Contacting your insurance provider directly will provide the most accurate information regarding coverage, reimbursement, and any potential additional costs associated with choosing an out-of-network orthodontist.

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 for braces even when they are not part of any network?

Yes, orthodontists can still accept insurance for braces even if they are not part of any network. When an orthodontist is out-of-network, it means they do not have a contracted agreement with a specific insurance provider, but they can still work with patients who have insurance coverage. Here's how it typically works:

  1. Fee-for-service: When you visit an out-of-network orthodontist, they will charge their regular fees for the services provided. These fees may or may not align with the insurance company's fee schedule or allowed amounts.
  2. Patient responsibility: As the patient, you will be responsible for paying the full amount charged by the out-of-network orthodontist. This includes any deductible, co-pays, or coinsurance as determined by your insurance plan.
  3. Reimbursement process: After paying the orthodontist, you can submit a claim to your insurance company for reimbursement. The insurance company will review the claim and determine the eligible amount based on their out-of-network policies and fee schedule.
  4. Out-of-network benefits: Depending on your insurance plan, out-of-network benefits may be available. The insurance company will typically reimburse you a percentage of the allowed amount for covered services, and you may receive the reimbursement directly.

It's important to note that out-of-network coverage may vary between insurance plans, and the reimbursement amount can be lower than what you would receive for an in-network provider. Additionally, there may be certain limitations or higher out-of-pocket costs associated with choosing an out-of-network orthodontist.

Before proceeding with treatment, it's recommended to contact both the orthodontist and your insurance provider to understand the financial implications and potential reimbursement for out-of-network orthodontic services.

Does health insurance cover braces differently depending on your plan?

Yes, health insurance coverage for braces can vary significantly depending on your specific health insurance plan. Insurance plans have different policies and levels of coverage, so it's important to review your plan documents or contact your insurance provider to understand the details of your coverage. Here are some ways in which health insurance may cover braces differently depending on your plan:

  1. Plan type: Different types of health insurance plans, such as HMO, PPO, or EPO, may have varying levels of coverage for braces. For example, an orthodontic benefit may be included in some comprehensive plans but not in others.
  2. Age restrictions: Insurance plans often have age limitations for orthodontic coverage. Some plans may provide coverage for children only, while others may extend coverage to adults as well.
  3. Network restrictions: Insurance plans typically have a network of providers with whom they have negotiated contracts and discounted rates. If you visit an orthodontist within the network, you may receive greater coverage and cost savings compared to visiting an out-of-network provider.
  4. Deductibles and co-pays: Insurance plans usually have deductibles and co-pays that you must pay before the coverage kicks in. The specific amounts can vary depending on your plan. For example, you may have to meet a certain deductible before the insurance starts covering a portion of the orthodontic treatment costs.
  5. Maximum benefit: Health insurance plans often have a maximum benefit or lifetime limit for orthodontic treatment. This limit indicates the maximum amount that the insurance company will pay toward braces or orthodontic services over your lifetime or a specific period.
  6. Pre-authorization requirements: Some insurance plans may require pre-authorization or a referral from a primary care physician before starting orthodontic treatment. This ensures that the treatment is deemed necessary and meets specific criteria for coverage.

Remember, it's essential to review your insurance plan documents, including the Summary of Benefits and Coverage, or contact your insurance provider directly to understand the specifics of your coverage for braces. This will help you determine the extent of coverage, any out-of-pocket costs, and any requirements or restrictions associated with your plan.

How to get your braces covered by insurance

To increase your chances of getting your braces covered by insurance, you can follow these steps:

  1. Review your insurance plan: Carefully read your insurance plan documents, including the Summary of Benefits and Coverage, to understand the orthodontic coverage details. Take note of any age restrictions, network requirements, deductibles, co-pays, and maximum benefit limits.
  2. Contact your insurance provider: If you have any questions about your coverage or need clarification on specific details, reach out to your insurance provider directly. They can provide accurate and up-to-date information about your plan's orthodontic coverage.
  3. Verify medical necessity: Inquire about the specific criteria for orthodontic coverage. Some insurance plans require a demonstration of medical necessity, such as a significant functional or structural issue with your teeth or jaw, before they will cover orthodontic treatment. Your orthodontist may need to submit supporting documentation and X-rays to prove the necessity.
  4. Find an in-network provider: If your insurance plan has a network of preferred providers, it is often beneficial to choose an in-network orthodontist. In-network providers have negotiated agreements with the insurance company, which can result in better coverage and reduced costs for you. Confirm with your insurance provider whether your chosen orthodontist is in-network.
  5. Pre-authorization: Some insurance plans require pre-authorization for orthodontic treatment. This means obtaining approval from the insurance company before starting treatment. Your orthodontist can assist you in the pre-authorization process by submitting the necessary documentation and treatment plan.
  6. Understand financial responsibilities: Even with insurance coverage, there may still be out-of-pocket costs. Familiarize yourself with any deductibles, co-pays, or coinsurance that you may be responsible for. Additionally, clarify the coverage percentage for braces and whether there are any limits or waiting periods.
  7. Keep records and documentation: Maintain detailed records of all communication with your insurance provider, including names, dates, and summaries of conversations. It's also important to keep copies of any submitted claims, pre-authorization forms, and receipts for payments made.

Remember, insurance coverage for braces can vary, so it's crucial to thoroughly understand your specific plan's requirements and limitations. Consulting with your insurance provider and working closely with your orthodontist can help ensure a smooth process for getting your braces covered.

What to do if you can’t afford braces...

If you can't afford braces, there are several options you can explore:

  1. Seek out orthodontic payment plans: Many orthodontic practices offer flexible payment plans that allow you to spread out the cost of braces over an extended period. These plans may involve monthly payments or financing options with little or no interest. Speak with your orthodontist to discuss payment options that can better suit your financial situation.
  2. Inquire about discounted fees or scholarships: Some orthodontic practices may offer discounted fees or scholarships for patients with financial constraints. Contact different orthodontists in your area to inquire about any available programs or reduced-cost options.
  3. Research dental schools or orthodontic residency programs: Dental schools and orthodontic residency programs often provide orthodontic treatment at lower costs as part of their training programs. While treatment may take longer due to the learning process involved, the fees tend to be more affordable. Contact local dental schools or universities with orthodontic programs to inquire about their services.
  4. Explore charitable organizations: There are charitable organizations that offer orthodontic assistance to individuals who cannot afford braces. These organizations typically have specific criteria for eligibility and may have limited resources, but it's worth researching and applying to see if you qualify for any assistance.
  5. Consider dental insurance or discount plans: If you don't currently have dental insurance, exploring insurance plans or dental discount plans may help reduce the cost of braces. Dental insurance plans that cover orthodontic treatment can provide significant savings. Dental discount plans, on the other hand, offer discounted rates for dental services, including orthodontics, in exchange for a membership fee.
  6. Discuss alternative treatment options: Depending on your specific orthodontic needs, there may be alternative treatment options available that are more affordable than traditional braces. For example, clear aligners or removable appliances might be more cost-effective for certain cases. Consult with your orthodontist to explore potential alternatives that align with your budget.

Remember, it's crucial to consult with an orthodontist to determine the best course of action for your specific dental needs. They can assess your situation, provide guidance on treatment options, and work with you to find a solution that fits your budget.

Where does SuperDial come in?

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About the Author

Morgan Sinclair

After starting her career as a dietitian, Morgan realized how much of a gap exists between clients with eating disorders and accessibility to care. She enjoys supporting clients and their families in navigating healthcare to receive care that they need, and does this through her marketing role with SuperBill and her design + strategy studio supporting clinicians and their online presence.