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Roxbury Medical Building
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Building A - Suite 1
Hackettstown, NJ 07840
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Does my insurance cover braces? Friday, 23 September 2016

This is a complicated question.  Orthodontic insurance is separate from medical and dental.  If you have dental insurance, most likely you have orthodontic benefits.  Orthodontic benefits are separate from your normal dental insurance with your dentist.  Orthodontic benefits are paid over the course of the treatment for the patient and normally have a lifetime maximum or co-pay per patient.  The normal time for braces is 24 months.  In that case, your benefit would be paid over 24 months.  Only 1% of insurance companies pay your orthodontic benefit in full in one payment.  There are medical plans that have orthodontic benefits only if the braces are medically necessary and your plan includes orthodontic benefits.  See below for examples of different scenarios. 

Orthodontic benefits work in several ways: 

The most common benefit is payable at a percentage with a lifetime maximum of a certain amount.  For example:  payable at 50% with a lifetime maximum of $1500 per person.  Let us say the total charge for braces is $6000.  The insurance company covers 20% down when the braces are put on:  $1200 and this is covered at 50%.  The insurance company will pay $600 when you get the braces on and you are responsible for the remaining 50%: $600.00.  The remaining balance of $4,800 is divided by 24 months (the course of the treatment): $200 per month.  The insurance company pays this amount at 50%, which is $100 per month until you have reached your maximum benefit.  In this case it is $1,500.  If you take the $1,500 minus the $600 paid at the banding date of the braces and $100 per month thereafter, you will run out of benefits in 9 months.  After the 9th month your responsibility would be the full $200 for the remaining months instead of the $100 per month for the first 9 months.  In reality, the braces are $6,000 minus your $1,500 benefit with a remainder of $4,500 that is your responsibility.

Some people have an orthodontic benefit as a percentage.  The most common percentage is 50%.  This is calculated as above:  $6,000 total charge, 20% down ($1200), and $200 per month for 24 months.  In this case, the insurance company will pay $600 down and $100 per month for 24 months.  The patient is responsible for the same. In this case 50% is $3,000 payable in installments of $600 down and $100 per month. 

Most managed care orthodontic plans have a fixed co-pay.  The most common co-pay is $1,200 or $1,000.  In these cases, you would have to pay your co-pay and the insurance company will pay the remaining balance of the full charge over the course of treatment (24 months).  If braces are $6,000 and your fixed co-pay is $1,000, you would pay $1,000 and the insurance company would pay $5,000 in installments.

Some managed plans cover at a percentage.  For example the insurance company will cover 75% of the total fee.  The patient is responsible for remaining 25%.  The 25% is considered your co-pay and the insurance company will pay the remaining 75% over the course of treatment.  For example, if the braces are $6,000, 75% is $4,500 that the insurance company will cover in installments.  Your 25% portion would be $1,5000.

The medically necessary insurance only covers braces with approval from a consulting orthodontist from their insurance company.  If approved, the insurance company covers 100% after a yearly deductible for the patient.  In most cases, it is $350 per year.  Remember, braces are for two years and you would have to pay that deductible every January each year the patient has the braces on.  If you start in the middle of the year, you might have 3 years of deductibles because it is charged every January of every year for the treatment plan.

How is your orthodontic benefit actually paid?

How your insurance company pays your benefit over the course of treatment varies.  The initial down payment is the first payment for all of the insurance companies when your orthodontic treatment starts.  The remaining balance will be paid in several installments.  Payments are either paid monthly, quarterly (3 monthly payment in one check), semi annually (benefit paid in 4 installments over the 2 years of treatment), or annually (50% of your benefit when you get the braces on and 50% a year later).  Rarely, but happens, your benefit will be paid in one lump sum when treatment starts.

If you move during the course of your orthodontic treatment, your insurance company must be informed and the installment payments of your benefit remaining will be stopped to your orthodontist.   

Changing employers and/or insurance companies during the course of your orthodontic treatment.

If you are working for the same employer and that employer changes insurance companies during your orthodontic treatment, you can submit a claim to the new insurance company.  That claim will be prorated according to the date the braces were put on and how many months of treatment are required.   The new insurance company will consider how many months the prior insurance company has paid and how many months are left of treatment.  In this case, usually, the new insurance company picks up the payments where the other company has left off.  The word usually is used because when you have the same employer, your benefits should continue even though your employer has changed insurance companies.  But, in some cases, there might be a pre-existing clause in your new benefit and the new insurance company will not continue payments.  If this is the case, you should try to appeal to get your full benefit from your employer.

If you change employers, your benefit from the first employer will be stopped automatically.  You can submit a claim to your new insurance company from your new employer and location.  The new insurance should pick up payments when your new orthodontist sends in a claim and submits the amount of months left of treatment.  Sometimes this is not covered due to a pre-existing clause in your new benefit.

 

In a nutshell:  Insurance is complicated for orthodontic treatment due to the length of treatment and different plans.  It is important to know your benefit, lifetime maximum, how it is paid and at what percentage.

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