Understanding your Orthodontic Benefits
Our goal is to make open enrollment season as clear as possible. Please review the information below to understand your orthodontic coverage and how changes to your benefits can affect your account during active treatment. If your insurance coverage changes during treatment, please contact our finance department right away. Our knowledgeable finance team is happy to walk you through the process. Please be aware that insurance companies set deadlines for filing claims, and benefits may be denied if a claim is submitted too late.
Questions to Consider When Selecting or Changing Insurance Plans:
- Does my plan include orthodontic coverage? Having dental insurance does not guarantee orthodontic coverage. Confirm that your plan covers both, and whether orthodontic coverage applies to adults and children or to children only.
- Is there a waiting period? Some plans cover cleanings and general dentistry immediately but require a waiting period before orthodontic benefits begin. Ask whether your plan has one. If it does, benefits will not be paid until the waiting period ends, so you may wish to schedule treatment to begin after that date. If treatment has already started, waiting-period plans typically will not cover work in progress.
- How are benefits calculated? Orthodontic coverage typically includes a Lifetime Maximum (LTM) benefit and a coinsurance percentage. The plan pays that percentage of the treatment fee, up to the LTM or allowed amount, as determined by the insurance company. Both figures vary by plan and may differ for out-of-network providers. Example: With a $2,000 LTM and 50% co-insurance, treatment would need to cost $4,000 or more for you to receive the full benefit. If treatment costs less than $4,000, the plan would only pay 50% of the actual fee.
- Can I have dual coverage? Yes, but rules and limitations may affect how the secondary plan will pay. This depends on each plan’s coordination of benefits (COB) policy. Ask the secondary plan what coordination of benefits it has.
- How are primary and secondary insurances determined?
- Married Parents: When a child is covered under both parents’ plans, insurances generally follow the birthday rule. Under the birthday rule, the plan of the parent whose birthday falls earlier in the calendar year (month and day, not year of birth) is generally primary. For example, if one parent’s birthday is 2/14/1973 and the other’s is 11/20/1968, the first parent’s plan would generally be considered primary. Age is not a factor.
- Separated or Divorced Parents: Insurers generally follow the court decree if one exists to determine which plan is primary.
- Adult Patients: An adult’s own plan is typically primary over a spouse’s plan.
- How does coordination of benefits affect what insurance will pay?
If you have dual insurance, Coordination of Benefits (COB) of the secondary insurance plan can affect if that plan will pay.
- Standard: When the secondary plan has a standard COB, both the primary and secondary plans will pay out the co-insurance amount up to the LTM, not to exceed the total treatment fee.
- Non-Duplication clause: If the secondary plan includes a Non-Duplicating clause, benefits will not be duplicated. If both plans have a $1,500 LTM, only the primary benefit could be used. If the secondary plan has a higher LTM, it will only pay the difference between the primary LTM and the secondary LTM.
- No Dual clause: If the primary and secondary plans are through the same employer/group, a No Dual clause will prevent the secondary plan from paying.
- Can I drop my orthodontic coverage after treatment starts or at my next open enrollment? How will this affect the expected insurance payment? Typically you shouldn’t drop your coverage, as orthodontic benefits are paid over the course of treatment rather than as a lump sum. Our office bills the full fee up front when appliances are placed; however, the payment schedule is determined by your insurance carrier and group. Most insurance plans pay out benefits on a monthly, quarterly, or annual basis over the full estimated treatment time. For example, if your orthodontist estimates two years of treatment, you should keep your coverage active for those two years. If your drop your coverage before the estimated treatment time or before the insurance has paid out the expected benefit, you will forfeit the remaining benefit and will be responsible for any unpaid balance.
- What if I gain orthodontic coverage after treatment begins? Employers sometimes expand benefits, or you may change employers and gain coverage you did not have at the start of treatment. Ask your new plan whether it covers work in progress. If it does, the benefit is generally pro-rated based on the remaining treatment time. If you change employers, there may be an unpaid insurance balance from the termed insurance. Your new insurance benefits may cover all or part of this unpaid balance. Any unpaid insurance becomes your responsibility.
If you have any additional questions please feel free to email finance@molensmiles.com.