Some patients may find that their dental insurance will cover a certain amount towards orthodontic treatment. Dental plans vary considerably, and every company/employer has their own specifications, so this section will only deal in general terms.

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Webster’s defines insurance as, “coverage by contract whereby one party undertakes to indemnify or guarantee another against loss by a specified contingency or peril”. Insurance is most commonly used in the case of medical issues (health and life insurance), and personal property (homeowners and car insurance). In each of these situations, it can easily be seen that a catastrophic event leading to the destruction of health, property, or life can lead to significant hardships. Insurance companies provide a means to spread the costs and risks, so that events such as these will not result in personal financial ruin.

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Dental insurance, or more specifically orthodontic insurance, does not follow this concept completely. Since in dental situations, patients find that regular and routine work is more the norm than the exception. Except in the case of severe injury to the face, significant expenditures on dental work are not common for many people. This is also the case for orthodontics, since for most patients, the need for treatment tends to be elective. Despite the elective nature of treatment, insurance companies and employers choose to sometimes offer braces as a benefit on dental plans since many people find orthodontic treatment of significant value.

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It is important to understand the potential insurance benefits before any treatment begins. If a patient does have orthodontic insurance, the best way to find out the coverage is to look at the certificate of coverage for the dental plan. Another option is to call the insurance company directly. Most orthodontic offices will also have staff available to look into benefits.

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What will insurance cover?

Often the first visit to the orthodontist is free and will not result in any charges. In this case, an insurance claim is not needed. However, it is beneficial to have the insurance information available at the first visit since the office staff can help determine the available coverage. An insurance card, the contact number for the insurance company, the insured ID number, and birth date are usually required.

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Since every plan is different, the following should be kept in mind: covered percentage and lifetime maximum, how the benefit is paid, coordination of benefits, covered percentage, and lifetime maximum.

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Covered Percentage and Lifetime Maximum

Orthodontic insurance tends to differ from medical insurance in that the entire treatment costs are rarely covered entirely by insurance. It is important to know not only how much of the fee your benefit will cover (i.e. the percentage), but also if there is a maximum amount of the benefit. A plan that has 50% coverage unfortunately does not necessarily cover half of the fee. Many times the insurance plan will have a defined lifetime maximum (for example $1000). The actual amount can be quite variable, usually ranging from $500 to over $3000.

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How the benefit is paid

Every insurance plan will pay the benefit differently. Some companies will pay the full benefit at the start of treatment, while others pay throughout the course of treatment on a monthly or quarterly basis.

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Coordination of benefits

If there is more than one insurance covering treatment for a patient, be aware that each plan may have conditional coverage based on what another plan may pay. Most insurance companies will coordinate the benefits using a birthday rule. That is, the insured with the earlier month/day of their birthday will be considered primary, while the other will be considered secondary. For example: Delta Dental – Primary Insured Birthday is 4/20/70 50% Benefit, $1500 lifetime maximum Cigna – Secondary Insured Birthday is 9/10/65 50% Benefit, $1000 lifetime maximum In this example, if there is a standard coordination of benefits, Delta and Cigna would both pay their benefits. However, if the benefits are considered non-duplicating, Delta would pay the full $1500, while Cigna would not pay anything (Delta has already paid over the benefit limit of the Cigna plan). This example shows why it is important to make sure that the benefits and coordination of all insurances are investigated prior to beginning treatment.

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Be aware that the fees for treatment are entirely the responsibility of the patient/parents. While some orthodontic offices will accept payments directly from the insurance companies, this does not remove the obligation on the part of the responsible party for the remaining fee. Insurance is many times a benefit provided by an employer. As such, if a job is lost or if the employer decides to cancel or change the insurance, the remaining fee for the braces will be entirely the responsibility of the patient/parents.

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While insurance can sometimes seem difficult to understand and deal with, the benefits provided can help reduce the financial burden. Just remember to provide as much information to the office staff so that they can help provide the most accurate information about costs and payment. Contacting the insurance company prior to the first appointment may also help fully understand the potential benefits.