Adolescent braces can be an intimidating step as your children grow up. At a cost of thousands of dollars, it can be a source of stress while you try to discern what your dental insurance might or might not cover. Get started with these questions to understand and maximize the value of your dental insurance plan.
Does our dental coverage include orthodontics?
This might seem basic but check it out. About half of employed Americans are eligible for dental plans at work. Plans vary tremendously. Some employers even offer different tiers of dental coverage you can choose from when you enroll in benefits. Dental plans tend to categorize treatment into categories like preventative care, basic procedures, or major procedures. Many dental providers will list out orthodontia specifically and what it covers. If you’re not sure, call the company and ask about coverage for adolescent orthodontics. As an aside, adult braces are often covered differently (or possibly not at all) by insurance providers.
Is there a waiting period and does it apply to my family’s situation?
Part of determining insurance coverage for your son or daughter’s braces will be determining if there’s a waiting period. Some dental insurance plans require that your family has coverage for a period of time before the company will help pay for braces. This may not apply, but if it does the details could be important. For example, a plan could require your family to be insured for 6 months before braces are covered. Other procedures like cleanings or preventative care could be covered with no waiting period. A waiting period, if it applies, generally would not exceed more than a year.
Does the plan have different coverage for in-network orthodontists? Is the provider we’re considering in the network?
All insurance providers, dental included, can make agreements with certain medical practices and doctors. Orthodontists who have entered into an agreement with the insurance provider are consider “in-network”. Every other provider is considered “out-of-network”. An important step will be to determine if your dental insurance makes this distinction. If they do, going to an in-network dentist will make a huge impact on the cost. Insurance could cover a small amount or none at all for an out-of-network provider. Most providers have a way to look up on their website to see if your local orthodontist is in their network. Many orthodontic offices can help answer this question as well if you tell them your insurance provider.
"All your children shall be taught by the Lord, and great shall be the peace of your children." Isaiah 54:13 ESV
How much of the treatment is covered?
Dental plans rarely cover the entire cost of adolescent braces. It will be important to determine what your provider covers. This could be a percentage of the cost or a maximum dollar amount.
What is covered by the plan and what is my responsibility (deductible, co-pay, etc)?
After you determine what the plan covers, you’ll need to see what your family’s responsibility is. Check to see if this is based on coinsurance, copays, or other terms.
Does the insurance company pay the orthodontist directly or reimburse my family?
Some dental insurance plans require you to pay for the entire cost of a procedure up front. For any amounts covered by insurance, they then reimburse you at a later time. This trips some folks up given the contrast to how most medical insurance plans handle coverage. Ask to see if your provider reimburses and the typical timeframe so you know what to expect and plan for.
Is there a lifetime limit?
Some dental plans have what is called a “lifetime limit” for orthodontics. This is a maximum per person the insurance provider will pay toward braces for an individual. For example, your son gets braces this year and you use insurance to help pay the cost. Several years later, the doctor recommends an additional round of braces. The insurance company might not cover the second treatment due to their lifetime limit. This is per individual so each child in your family would have their own lifetime-limit while on your dental insurance plan.
A word about “other” insurance
Although rare, there are cases where your medical insurance will cover a portion of orthodontic costs. This uncommon scenario would apply if your child were getting braces for a “medically necessary” reason that fits your medical coverage provider’s criteria. Your orthodontist should make you aware if your child’s situation is outside of a typical orthodontic treatment.
How to get started
Because dental insurance websites can be difficult to navigate, a phone call might be warranted to get a answers to some of these questions. Don’t be afraid to ask questions until you feel confident about how the dental insurance provider will treat your child or teenager’s orthodontic treatment. You are paying for a service and have a reasonable right to understand your coverage.
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