Does my insurance cover braces? | Orthodontic Specialists | Succasunna New Jersey
does the insurance cover the brakes? How do I know if my insurance covers orthodontics? How much does brake insurance cover? orthodontic lifetime maximum? Can I change orthodontic insurance during treatment? How does orthodontic insurance work? Does dental insurance cover braces? How are the brakes billed to the insurance?
These are tricky questions to give a general statement for all situations, but I’ll try. Orthodontic insurance is separate from medical and dental insurance. If you have dental insurance, you most likely have orthodontic benefits. Orthodontic benefits are separate from your regular dental insurance with your dentist. Orthodontic benefits are paid over the course of treatment for the patient and typically have a lifetime maximum or copay 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 orthodontia benefit in full in one payment. There are medical plans that have orthodontia benefits only if the braces are medically necessary and your plan includes orthodontia benefits. see below for examples of different scenarios.
orthodontic benefits work in several ways:
The most common benefit is paid as a percentage with a lifetime maximum of a certain amount. for example: payable at 50% with a lifetime maximum of $1,500 per person. Let’s say the total charge for brakes is $6,000. the insurance company covers 20% when the braces are put on: $1200 and this is covered at 50%. the insurance company will pay $600 when your braces are put 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 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 on the date of braces placement 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 $100 per month for the first 9 months. Actually, the braces are $6,000 minus your $1,500 benefit with the rest of $4,500 being 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 payment ($1,200), 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 it. in this case, 50% is $3,000 payable in installments of $600 down payment and $100 per month.
Most managed care orthodontic plans have a fixed copay. the most common copay is $1,200 or $1,000. in these cases, you will need to pay your copay and the insurance company will pay the remaining balance of the full charge over the course of treatment (24 months). If braces cost $6,000 and your fixed copay 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 the remaining 25%. 25% is considered your copay 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% share would be $1,5000.
Medically necessary insurance only covers braces with the approval of a consulting orthodontist from your insurance company. if approved, the insurance company covers 100% after an annual deductible for the patient. in most cases, it is $350 per year. remember, the braces are for two years and you would have to pay that deductible every January of every year the patient has the braces on. if you start in the middle of the year, you may have 3 years of deductibles because it is billed every January of every year for the treatment plan.
How is your orthodontic benefit actually paid?
How your insurance company pays your benefit during the course of treatment varies. The initial payment is the first payment from all insurance companies when you begin your orthodontic treatment. the remaining balance will be paid in several installments. Payments are paid monthly, quarterly (3 monthly payments in one check), semi-annually (benefit is paid in 4 installments over 2 years of treatment), or annually (50% of your benefit when you get your braces and 50% year). year later). on rare occasions, but it does happen, your benefit will be paid in a lump sum when treatment begins.
If you move during the course of your orthodontic treatment, your insurance company must be notified and installment payments of your remaining benefit to your orthodontist will be stopped.
change employers and/or insurance carriers during the course of your orthodontic treatment.
If you work for the same employer and that employer changes insurance carriers during your orthodontic treatment, you may file a claim with the new insurance carrier. that claim will be prorated based on the date the braces were placed and how many months of treatment are required. The new insurance company will consider how many months the old insurance company has paid for and how many months of treatment remain. In this case, the new insurance company usually picks up where the other company left off. The word is generally used because when you have the same employer, your benefits must continue even if your employer has changed insurance companies. but, in some cases, there may 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 the full benefit from your employer.
If you change employers, your benefit from the first employer will automatically stop. You can file a claim with your new insurance company from your new employer and location. Payments must be collected by the new insurance when your new orthodontist submits a claim and submits the remaining number of months of treatment. sometimes this is not covered due to a pre-existing clause in your new benefit.
Bottom line: 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.
how are insurance billed for brakes?
Our office handles all billing to insurance companies. unlike most offices that don’t handle all the form submissions and payments!
How do I know what my insurance coverage is?
just send doreen an email! > [protected email]
what information is needed to assess coverage?
- dental insurance name
- dental insurance phone number
- name of policyholder
- social security number of the policyholder
- policy holder’s date of birth
- policyholder identification number
- policyholder group number
- name of the policyholder’s employer company
- patient name
- patient’s date of birth
- patient zip code
Will orthodontic specialists find out the amount of my coverage?
yes! simply email my receptionist doreen at [email protected] copy and paste the list of required information above to doreen and we will get you or your child covered.
