Orthodontic Insurance: What Families Should Know Before Starting Braces or Aligners

Orthodontic Insurance: What Families Should Know Before Starting Braces or Aligners

One of the more confusing parts of starting orthodontic treatment is figuring out what insurance will actually cover. Most families are familiar with dental insurance. They use it for cleanings, X-rays, fillings, and routine dental visits, so it is natural to assume that if a plan includes dental benefits, it must also include orthodontic benefits.

But orthodontic insurance works a little differently.

A dental plan may include orthodontic coverage, but it may not. In many cases, orthodontic coverage is something an employer has to specifically choose to include when setting up the dental plan. You may hear this referred to as an orthodontic rider. That means two people can have dental insurance through the same insurance company, but only one may have orthodontic benefits, depending on what their employer selected.

This is one of the reasons orthodontic insurance can be so surprising. A family may look at their card, see a well-known dental insurance company, and assume braces or aligners will be covered. Then, when benefits are checked, they find out that the plan covers dental care but not orthodontic treatment. Other times, the plan does include orthodontics, but the amount covered is different from what the family expected.

The biggest difference is that regular dental benefits usually have an annual maximum. If your dental plan pays up to a certain amount each year, that amount often resets when the new benefit year begins. Orthodontic benefits usually do not work that way. Most orthodontic plans have a lifetime maximum.

A lifetime maximum means the insurance company will pay up to a certain total amount toward orthodontic treatment. Once that amount has been used, it does not start over next year. For example, if a plan has a $1,500 lifetime orthodontic maximum, that is usually the total orthodontic benefit available under that plan.

This is also where the phrase “insurance pays 50%” can become confusing.

When someone is told their orthodontic insurance pays 50%, it may sound like the insurance will pay half the total cost of braces or aligners. Usually, that is not what it means. More often, the plan pays 50% of covered orthodontic charges until it reaches the lifetime maximum.

So if treatment is $7,000 and the plan has a $1,500 lifetime orthodontic maximum, the insurance is not necessarily paying $3,500. It may pay 50% only until the $1,500 maximum has been reached. That is still helpful, but it is very different from what many people picture when they hear “50% coverage.”

Another thing families are often surprised to learn is that orthodontic insurance may pay the same amount whether the orthodontist is in-network or out-of-network. This is different from many medical insurance plans, where network status can make a huge difference. With orthodontics, many plans simply pay the allowed orthodontic benefit either way. Because of this, we are able to accept most insurance plans.

Of course, every plan is different. Some plans do have network rules, waiting periods, or other restrictions. But in many cases, the most important thing to know is not just whether an office is listed as in-network. The more important question is how much orthodontic benefit is available and whether that benefit can be assigned directly to the orthodontic office.

Some plans also say they cover orthodontics only when it is “medically necessary.” That phrase can sound encouraging, but the requirements are usually very strict. This comes up more often with some adult plans, some Medicare Advantage dental benefits, and certain limited dental policies. Crowding, spacing, overbites, underbites, impacted teeth, or bite problems may be very real orthodontic concerns, but they may not meet the insurance company’s definition of medical necessity.

That does not mean treatment is not important. It simply means the insurance company may have a very narrow definition of what qualifies for payment under that particular plan.

The best way to understand your benefit is to ask very specific questions. Calling the number on the back of your insurance card can be helpful, but general questions often lead to general answers. Instead of asking only, “Do I have orthodontic coverage?” it is better to ask for the details.

Here are the questions we recommend asking:

* Does my dental plan include orthodontic coverage?

* Was orthodontic coverage included by my employer, or is it only available if an orthodontic rider was selected?

* What is the lifetime orthodontic maximum?

* Has any of that lifetime maximum already been used?

* Does the orthodontic benefit reset each year, or is it truly a lifetime maximum?

* What percentage does the plan pay toward orthodontic treatment?

* Is that percentage based on the total treatment fee, or only up to the lifetime maximum?

* Is there a waiting period before orthodontic benefits begin?

* Are braces and clear aligners covered the same way?

* Are appliances, expanders, or early orthodontic treatment covered?

* Is orthodontic treatment covered only if it is considered medically necessary?

* If medical necessity is required, what conditions qualify and what documentation is needed?

* Does the plan pay the same amount in-network and out-of-network?

* Can benefits be assigned directly to the orthodontic office?

* Does the insurance company pay the orthodontic benefit all at once, monthly, quarterly, or over the course of treatment?

* Are there any exclusions if treatment has already started?

* Is there a deductible that applies to orthodontic treatment?

* What information does the orthodontic office need to submit for benefits to be paid?

Orthodontic insurance can be helpful, but it is much easier to understand when you know what to ask. The percentage listed on the plan is only part of the picture. The lifetime maximum, waiting periods, medical necessity language, and payment schedule all matter.

If you are considering braces or aligners and are unsure what your insurance covers, we are happy to help. Bring your insurance information with you to your free consultation, and our team can check your benefits and explain how they may apply to your treatment.

Our goal is to help you understand the full picture before you start, including treatment options, total cost, payment options, and any insurance benefit available to you.