Our goal is to eliminate confusion when it comes to your company’s open enrollment season. Please read below to understand your orthodontic coverage and how benefit changes can affect your account during active treatment. If your insurance coverage changes during treatment please contact our finance department as soon as possible. Most insurance companies have time limitations when it comes to filing claims, if the claim is filed too long after the plan becomes active, benefits could be denied.
Things to review with your plan provider:
- 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.
- Orthodontic coverage typically involves a Lifetime Maximum (LTM) Benefit and a copay percentage, which covers a portion of the fee up to the preset LTM amount. The percentage and dollar amount can vary depending on the plan. For example; if your LTM benefit is $2500, and the copay percent is 50%, the braces would have to cost $5000 or more for you to use your full benefit. If the treatment cost is below your LTM, then the Insurance Company will only pay 50% of treatment. *These amounts can vary based on out of network coverage as well.
- 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 active 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”.
- 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 a wait before orthodontic coverage is active. If a waiting period exists you can’t start treatment until the given date. If treatment has already began they typically will not cover work in progress. Be sure to ask your dental plan if there is a waiting period for braces as well as the question above if in active treatment.
- Can I have dual coverage for braces? It depends on your company’s coordination of benefits policy, and how they determine primary vs. secondary. Ask the secondary plan if the 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. If the plan has a Non-duplicating clause or No Dual clause it means benefits will not be duplicated. For example, if both plans have a LTM of $1500 then with a non-duplicating clause you can only use the primary benefit. When coordination of benefits is allowed your benefit could be as high as $3000 if the LTM for both plans is $1500. In split family situations the insurance company will leave it up to the parents and/or court documentation to determine coordination of benefits.
- 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.
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