During orthodontic treatment, if insurance coverage is interrupted (terminated) for any reason, insurance payments stop. Reasons may include a job change, employer changing insurance carriers, coverage is dropped, or treatment ends.
Full Answer
How much will my insurance pay for orthodontic treatment?
The answer to this is, it depends. Most plans will pay for 50%, up to the lifetime maximum. Here’s an example of an 24-month orthodontic treatment breakdown for a patient who has a PPO insurance that we are in-network with: “Wait…but why do I not receive the full $3000 benefit?”
What is a covered orthodontic service?
You may be wondering, “What is a Covered Orthodontic Service?” Most insurance plans cover specific portions of the entire orthodontic treatment. Commonly, insurance plans will cover metal braces but not upgrades such as clear/ceramic braces or Invisalign, as those options are considered to be cosmetic upgrades.
How does orthodontic coverage work with DMO plans?
Here's how orthodontic coverage works: If you switch back to the DMO plan, the months you were covered under the Indemnity or PPO/PDN plan will be deducted. That means no benefit is paid for that time period. DMO plan benefits are not subject to the Indemnity or PPO/PDN plan maximum.
Does my employer cover orthodontic work in progress?
Sometimes an employer will increase their plan benefits or you might even change employers and find yourself with orthodontic benefits that you did not have when you or your child first started treatment. The question to ask your new plan is if they cover work in progress.
What happens if you move in the middle of orthodontic treatment?
Sometimes families need to relocate while one of their family members is in the middle of orthodontic treatment. If the move is a significant distance, they likely will have to find a new orthodontist to continue their treatment.
Can you transfer orthodontists in the middle of treatment?
The answer is: yes, you can switch your orthodontist during treatment.
Will insurance cover braces more than once?
Orthodontic coverage typically involves a Lifetime Maximum Benefit (LTM) that pays out at 50% of the total case fee. There are a few plans that pay more or less than 50%. This means they will pay for braces 1 time and once you have used all of the LTM they won't pay any more.
What is limited orthodontic treatment?
Limited orthodontic treatment has a limited objective, not necessarily involving all the teeth present. It may be directed at the only existing problem, or at only one aspect of a larger problem in which a decision is made to defer or forego more comprehensive therapy.
Can I go to another orthodontist to get my braces removed?
Most patients remain with the same orthodontist throughout the entirety of their treatment plan, but yes, switching orthodontists during braces or Invisalign is possible!
Is it hard to switch orthodontists?
There may come a time during your orthodontic treatment when you need to relocate, and thus continue treatment at a different orthodontic office. Our office sees this situation fairly often since we're in a military community, and changing orthodontists is not as difficult as you may think.
What is Ortho lifetime maximum?
Unlike most insurance coverage, which has annual maximum benefits that renew each year, orthodontic benefits are usually lifetime maximums. This means that once you use the benefit, there is no more, and it will not renew.
What does braces fall under in insurance?
Dental insurance for braces, also called orthodontic insurance, is specific to orthodontic treatment. That includes braces, retainers, and other procedures designed to fix the alignment of your teeth and jaw. Orthodontic insurance isn't usually a standalone product.
How much do braces cost without insurance?
$3,000 to $10,000Average cost of braces without insurance. The price of braces can vary significantly but generally falls in the range of $3,000 to $10,000. It can also be more or less.
What is Phase 1 in orthodontics?
Phase 1 orthodontic treatment, or interceptive orthodontics, typically occurs between 6 and 9 years of age, during the mixed dentition phase, when patients begin to lose their baby teeth. The American Association of Orthodontists recommends that all children get a checkup with an orthodontist no later than 7 years old.
What is retention in orthodontics?
Retention is the part of orthodontic treatment that is designed to keep your teeth in proper alignment after your braces come off or your Invisalign clear aligner series is complete. In other words, retention ensures you keep the beautiful smile you and your local orthodontist have worked so hard on.
What is the difference between Interceptive and comprehensive orthodontic treatment?
Comprehensive orthodontic treatment starts when a child is between 11 and 14 years for boys and between 12 and 15 for girls. Interceptive orthodontics helps make comprehensive orthodontic treatment become less difficult for your child. Interceptive orthodontics prevents impacted teeth.
Do you have to have insurance to get orthodontics?
Many insurance plans to not require pre-approval for orthodontic treatment, and benefits will be paid as long as you are eligible. Yes, in many cases, our patients are able to start their orthodontic treatment on the same day as their consultation .
Does insurance cover braces?
Most insurance plans cover specific portions of the entire orthodontic treatment. Commonly, insurance plans will cover metal braces but not upgrades such as clear/ceramic braces or Invisalign, as those options are considered to be cosmetic upgrades. “Does this mean that I cannot have Invisalign or clear/ceramic braces if I have dental insurance ...
What happens when an orthodontist sells a practice?
When a practice sale does occur you may not be given a heads up and then entire process may feel abrupt. In this situation your selling orthodontist may be bound by a non disclosure agreement and may not be able to discuss plans to sell with current patients while the sale is pending.
What is the transfer process for orthodontics?
The transfer process involves multiple moving parts that must be coordinated well to streamline the process and get you back on the road to a successful orthodontic treatment. The initial step in this transfer process is making the decision to transfer your treatment.
How many people are in braces at any given time?
Patients needing to transfer orthodontic treatment mid-treatment is becoming more common. The American Association of Orthodontists estimates that close to 5 million people are in braces at any given moment. So this trend won’t be slowing down anytime soon as new patients begin to move, settle down, and look for orthodontic care.
How many people move to orthodontics?
A 2019 census.gov article states that in 2018, 10.1 percent of people (about 32.4 million) in the United States moved within the past 12 months. This means that many of the families that begin an orthodontic treatment move before their treatment has been completed. While getting into orthodontic treatment can be easy, ...
What is the emotional journey of orthodontics?
The orthodontic journey is filled with emotional highs and lows and requires empathy and understanding from your provider. While your complaints may seem like a pure sympathy play to a busy doctor, the active listening doctor will take your concerns seriously.
Can you transfer your orthodontic treatment to another provider?
If your office isn’t meeting your physical or emotional needs and you have discussed this with your current provider with no resolution, then you may consider transferring your treatment to another provider. Your orthodontic provider should be an active listener and sensitive to your physical needs while in the chair. The orthodontic journey is filled with emotional highs and lows and requires empathy and understanding from your provider.
Is an orthodontist retiring?
But one day you may call to book an appointment only to discover that your orthodontist is retiring or otherwise closing up shop. Typically orthodontists will send out announcement letters or emails to current patients in preparation for a retirement event. This will give you a heads up and some time to start looking for an office to transfer your treatment to. In most cases, the retiring doctor may have already established a tentative practice where you can be seen for emergencies and to potentially transfer your case.
How much does orthodontic coverage pay?
2. Orthodontic coverage typically involves a Lifetime Maximum Benefit (LTM) that pays out at 50% of the total case fee. There are a few plans that pay more or less than 50%. This means they will pay for braces 1 time and once you have used all of the LTM they won’t pay any more.
How much does insurance pay for braces?
If your benefit is estimated at $3000, the Insurance Company generally pays you or the orthodontist an initial payment when the braces are placed and then monthly, quarterly, or annual instalments for the remaining months of treatment.
How long do you have to keep braces?
If the orthodontist estimates that you will be in braces for 2 years then you would want to make sure you keep you dental plan during those 2 years . If you drop your dental/orthodontic insurance before your benefit has finished paying this can result more out of pocket expenses for you. 4.
What is the birthday rule for insurance?
The birthday rule determines whose plan is primary and looks at what month the person is born in. For example if mom’s birthday is 2/14/73 and dad’s birthday is 11/20/1968, mom’s plan, in most cases, would be considered the primary insurance plan because her birthday falls first in the calendar year.
Do orthodontic payments follow you?
If your employer changes plans while you or your child are still in treatment the orthodontic payment history will typically follow you. However, if you take out a new plan with a completely different company often times, the history does not follow you and this can result in additional benefits.
Is primary insurance primary or secondary?
The answer is yes in most cases but there are a few rules insurance companies follow when determining primary vs. secondary and you want to make sure your plan allows for standard coordination of benefits. The birthday rule determines whose plan is primary and looks at what month the person is born in.
Does dental insurance cover orthodontics?
1. Just because you have Dental Insurance does not mean you have orthodontic coverage. Be sure to ask if your plan covers both. Also be sure to ask if the coverage is for adults and children or just for children. Sometimes there are higher premiums for both dental and orthodontic Coverage but often times there are not.
What happens if my health insurance plan changes?
If your plan changes and you want to stay with your doctor, you will need to apply for transition of care. "The member must submit a transition of care request, typically signed by her doctor, before the change in plans is made," Coplin says.
How is a transitional care request reviewed?
Requests are reviewed by the insurer's staff in consultation with the medical director. After the review is complete, you will receive a letter confirming whether your request for coverage under transition of care has been approved. You can continue to see your doctors for a transitional period only.
What are some examples of transition of care?
Here are examples of situations that are likely to qualify for transition of care and allow you to remain with your original doctors or other providers even when they are no longer in your health plan: Chemotherapy or radiation therapy. Out-patient intravenous therapy for a resolving condition.
How many weeks pregnant do you have to be to get transition care?
There are some caveats to be eligible to apply for transition of care for pregnancy: You need to be at least 20 weeks pregnant unless your state or plan requirements are different. Or, you are less than 20 weeks but are considered and documented to be high risk by your providers.
Can I get treatment without penalty?
You will receive the treatments without penalty at your preferred plan benefit level. For example, if your request is approved and you have an HMO, you would be covered at the in-network benefit level regardless of whether your doctor is still part of your HMO network.
Can I apply for transition of care for pregnancy?
Pregnancy isn't the only reason you might apply for a transition of care from your health insurer. Transition of care applies to treatments for a diagnosed condition that has a defined number of services or periods of treatment and includes a qualifying situation, Coplin says.
When do you have to have braces on your teeth?
Orthodontic age limit: When the plan includes an orthodontic age limit, braces must be placed on your teeth before reaching your plan's specified age limit. Dependent age limit: Orthodontic benefits will be available until your dependent reaches your plan's specified age limit.
How long does DMO last?
DMO plan orthodontic benefits are based on a 24-month lifetime plan maximum. When you switch to a DMO plan, benefits for any remaining orthodontic treatment will be considered as one course of treatment limited to 24 months. * Illinois members: State laws vary with regard to out-of-network benefits. In Illinois, DMO plans provide limited ...
What does "work in progress" mean in Aetna?
Some plans have a work-in-progress exclusion. That means the plan will not cover treatment that started when you were covered by another plan. If your plan does not have a work-in-progress exclusion, we determine your coverage based upon: What is covered by your Aetna dental plan. Your current treatment stage.