With dental insurance becoming more prevalent in our society we get a ton of questions all the time regarding orthodontics and dental insurance.  Questions such as:

  • Does my insurance cover braces?
  • Does my insurance cover Invisalign?
  • How much does it cover?
  • Should I switch to a better insurance?

Hopefully this article well help answer YOUR questions.
There are two types of Insurances HMO and PPO dental insurances…let’s start with PPO.
PPO Insurance
PPO plans give you the freedom to choose any orthodontist that accepts your insurance and is in Network.  PPO plans to be more pricey but give you the flexibility to choose who you want in case you obviously want the “best” orthodontist or one that fits your needs.  (Check out the blog on How to Choose an Orthodontist.)
Most PPO plans cover orthodontic treatment.  The range is usually between $500-2500 lifetime benefit, meaning you can only use the amount once while you have the insurance.
Lifetime benefit Important points:

  1. They can only be used once! If you use it up for early treatment it cannnot be used it for Phase II orthodontic treatment.
  2. It is SEPARATE from your general dental benefit.  So you can still use your orthodontic benefit and your general dental benefits will not be affected.
  3. It IS NOT paid all at once, so you cannot use it, drop insurance and sign up for another one to get more benefit ;-p Insurance companies are smarter than us. It is paid in portions monthly quarterly depending on the insurance company.
  4. Sometimes it is not paid in full depending on the insurance company.  Orthodontist are unsure why this is the case but ultimately it is the company that decides what they want to cover or not. In this case it is the patients responsibility to pay the remainder.  It is what it is.

Percentage coverage: The percentage of coverage can be confusing.  Let’s use 50% since that is most typical percentage.  This essentially means that they will cover 50% of the covered benefit.  Ex: Let’s say your orthodontic treatment costs $3000 they will cover 50% up to the max of $1500. If the treatment costs only $2500 they will only cover $1250.   The rest can be used for something else orthodontically related.
Changing insurances:  Often times insurance companies know people will pick up an insurance just for the orthodontic benefit.  Many companies place a “waiting period” on their plans meaning you have to wear a certain ammount of time, usually 1 year, before you can utilize the orthodontic benefit.
If you change insurances often times they will no pick up treatment in progress. Double check with your insurance company prior to changing if you our your child is in orthodontic treatment.  If your employer changes their insurance company, they are required to pick up the tab of the prior insurance company.
Adult coverage:  As an adult if you are interested in orthodontic treatment make sure you check if “Adult orthodontics” is covered.  Most insurance only cover orthodontic coverage up to age 19.
Invisalign: The best thing to do is to check to see if you Invisalign is covered by your insurance company.  Some do some don’t.
HMO Insurance
HMO is a network of dental providers that accept your insurance.  Therefore you often need a referral from a General Dentist to another orthodontist “in Network”.  You are required to pay a set fee, set by the insurance company for orthodontic treatment anywhere with a network provider.
So if your set copayment for braces is $2000, you can go anywhere in network and you just have to pay $2000 regardless of the provider.  You may be charged other fees by the provider such as records fees, retainer fees, additional charges for clear braces or Invisalign, and this is required by law.  This fee/copayment unfortunately cannot be negotiated…it is against the law.
Hopefully this helps! Please comment if you have any additional questions and I will answer the best I can!  If there are experts that want to correct me by all means please let me know!