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“Is Orthodontic Treatment Covered by Insurance?” This is a great question that we get asked all the time in our practice. Dental insurance is widely available and many individuals have dental insurance through their employer. Depending on the dental plan, it may or may not offer orthodontic benefits. The natural follow-up question would be, “How do I find out if my plan provides orthodontic benefits?” It’s easy to determine whether you are eligible for orthodontic benefits by simply checking with your dental insurance provider. In addition to calling member services, most insurance providers offer the ease and convenience of an online account where you can check your eligibility for benefits. If you are unsure as to how to do this, feel free to call us at 914-923-5089 and we are more than happy to help as we are experienced in checking our patients’ eligibility.
Now that you know your insurance plan provides orthodontic benefits, the next question is, “How much will my insurance plan pay for orthodontic treatment?” Commonly, our patients will have a lifetime maximum allotted for orthodontic treatment, which means that it can only be used once and does not renew. Common lifetime maximums range from $1000-$3000, depending on your plan. “Does this mean that I can take advantage of the entire lifetime maximum?” The answer to this is, it depends. Most plans will pay for 50%, up to the lifetime maximum.
Here’s an example of an 24-month orthodontic treatment breakdown for a patient who has a PPO insurance that we are in-network with:
Comprehensive Orthodontic Treatment Contracted Fee: $5500
Patient’s Insurance Lifetime Maximum: $3000
Orthodontic Benefits: 50% for Covered Orthodontic Services
Approved Insurance Benefit: $2750
Patient’s Investment: $2750
“Wait…but why do I not receive the full $3000 benefit?” The only way that the patient would received the full $3000 benefit is if the orthodontic treatment is $6000, but since we are in-network, we have to accept the insurance plan’s fee schedule, which in this case is $5500. Since the insurance benefits are at 50%, the plan will pay $2750. Please note, there are many insurance plans available, and this is only one example. We offer several convenient payment options including the flexibility to pay over time.
Here’s nearly the same example, except the patient has an orthodontic benefit lifetime maximum of $1000.
Comprehensive Orthodontic Treatment Contracted Fee: $5500
Patient’s Insurance Lifetime Maximum: $1000
Orthodontic Benefits: 50% for Covered Orthodontic Services
Approved Insurance Benefit: $1000
Patient’s Investment: $4500
In this example, the patient is able to use the entire $1000 insurance benefit. Finally, please keep in mind that if treatment is estimated to take only 12 months, approximately half of the approved insurance benefit will be paid.
You may be wondering, “What is a Covered Orthodontic Service?” Most insurance plans cover specific portions of the entire orthodontic treatment. Commonly, insurance plans will cover metal braces but not upgrades such as clear/ceramic braces or Invisalign, as those options are considered to be cosmetic upgrades. “Does this mean that I cannot have Invisalign or clear/ceramic braces if I have dental insurance with orthodontic benefits?” Not at all! In most cases, patients can still take full advantage of their orthodontic benefits, and the upgrade for Invisalign or clear/ceramic braces will simply be the patients’ responsibility.
Finally, many patients ask us, “Do you need to send a pre-determination to my insurance company first, or would it be possible for me to get started on my treatment today?” Great question. Many insurance plans to not require pre-approval for orthodontic treatment, and benefits will be paid as long as you are eligible. Yes, in many cases, our patients are able to start their orthodontic treatment on the same day as their consultation.
We hope that this article helps you understand your dental insurance plan better. As always, give us a call at 914-923-5089 and we will do our very best to help!
