Dental insurance and orthodontic insurance can be confusing, which is why we are here for you! Our incredible financial coordinator, Cindi, helps all of our patients navigate their specific insurance plan to maximize their benefits. Here is a little information about orthodontic insurance to help you on your journey!
Cindi, Finance Coordinator
Orthodontic insurance is often a lifetime benefit. That means that the amount does not renew annually. Often the lifetime benefit is a set dollar amount (i.e. $1000-$3000) and a % of the treatment fee (usually 50%).
For example, lets say your orthodontic insurance has a lifetime benefit of $2000 at 50%. If your orthodontic treatment cost is $400, your insurance would cover up to 50% or $200. This also means that you will have $1800 remaining of your orthodontic insurance that could be applied to any future orthodontic treatment. This situation of having remaining benefits that can be used later often applies when our patients have two phases of orthodontic treatment. In another example, if your orthodontic treatment costs $5000 and you have the same orthodontic benefit, your insurance would pay the maximum of $2000 and you would be responsible for the remaining $3000.
Orthodontic insurance is often a “rider” to dental insurance. This means that just because you have dental insurance doesn’t always mean you have orthodontic insurance. It’s best to ask your employer or call Cindi. She is happy to help check your plan for you.
Insurance companies do not pay their portion in one lump sum. Often, they pay over the entire course of treatment, monthly, quarterly, or annually. This is important to remember, because if you lose or change your insurance during the course of orthodontic treatment, your insurance may stop paying. In this case, the responsible party would be responsible for the amount the insurance did not pay. If you are in a situation where you are changing jobs or insurance, it’s best to talk with Cindi. She can make sure you have all the information to make the best decision for you.
Some orthodontic insurances have a waiting period of 6-12 months. If you or your child is planning to start orthodontic treatment, it’s important to check your insurance ahead of time to make sure you don’t have to wait.
If you have two orthodontic insurance plans, these fall under the term “coordination of benefits”. Coordination of benefits uses the birthday rule. Whichever person’s insurance has a birthday earlier in the year, this person’s insurance is usually the “primary insurance” and the other insurance is the “secondary insurance”. If one insurance plan gives $1000 and the second plan gives $1500, they don’t usually add up to pay $2500 total. It is usually less, and based on the specifics of your plan. Regardless, having two insurance benefits is usually beneficial.
If you obtain orthodontic insurance in the middle of your treatment, this is considered a “work in progress” insurance claim. Insurance will often pay a prorated amount of your benefit based upon the length of treatment time and where you are in treatment.
As you can see, there are many nuances to orthodontic insurance. We are thankful to have such an informed financial coordinator in our practice to help you with your orthodontic journey!