What You Should Know About Orthodontic Insurance
We are happy to work with you and your insurance company to receive the maximum benefit possible under your policy, however the ultimate financial responsibility lies on the patient and his/her family. We have found that the more you know about your individual policy, the easier it is to process your claim. To assist us both in this endeavor, we have established the following answers to the most commonly asked questions:
How does orthodontic insurance work?
There are many different agreements between insurance carriers and their subscribers, and each contract provides a different benefit. For example: some programs pay monthly, others quarterly. Some programs cover adults and others cover only children. There may be other qualifications such as being with the program a year or longer before any benefits are available. Orthodontic insurance generally differs from regular medical insurance in that it rarely pays for orthodontic treatment in full. Each insured individual usually has a lifetime maximum benefit for orthodontic services. This benefit is generally spread out over the length of the orthodontic treatment. Please be aware that termination of any insurance policy before payment is received will also stop the insurance payments. Charges for lost or broken appliances are also not covered by insurance.
How Benefits Are Calculated
There is no universal formula for calculating the amount to be paid toward the initial appliance placement fee or subsequent monthly fees. Each policy maintains its own formula. It is common for orthodontic benefits to be paid at 50% of the treatment fee up to a lifetime maximum amount. Your policy may have a yearly deductible.
Flexible Benefits Plans and Executive Management Plans
Flexible Benefit Plans have become a very popular method of projecting “before tax” dollars to be spent during the next plan year. These types of plans commonly allow the insured to allocate a specified number of salary dollars toward certain expenses, usually medical, dental or child care expenses. Because these dollars are not subject to payroll taxes, they are a very attractive way of increasing the value of you “insurance dollars.” In most cases, there are very specific rules about when orthodontic treatment is initiated to receive the greatest benefit. You must declare the amount to be spent for the year prior to the beginning of the plan year. The plan year for the policy may not be a calendar year. You stand to receive the greatest benefit by planning how orthodontic treatment can fit into the rules of your Flexible Benefit Plan. You may wish to confirm the beginning of the plan year.
What If I Have Multiple Coverage?
If the patient is covered by more than one orthodontic insurance policy, the carriers will determine which plan is considered the primary policy. Often this determination is made by birthdates of the insured parties. This method of determination is not a universal formula, but is individual to each carrier. The secondary insurance carrier will not declare or pay benefits until the primary carrier has made a determination of treatment will be covered. The secondary carrier usually requires written confirmation from the primary carrier of the benefits to be covered.
How can you maximize your benefits?
Call your insurance company to learn as much as possible about your program. Ask how often it pays, lifetime maximum age limitation (when applicable), whether payment will start immediately when treatment is started, or whether there is a waiting period. Please be aware that if your policy changes during the time in treatment, benefits will also change and any money not received in the overall transition will be added to your balance, continuing your payments at the end of treatment. We pledge to help you achieve your full insurance benefit to the best of our ability.