Orthodontic benefits are separate from dental benefits. Even though you may be covered by dental insurance, you may or may not have orthodontic coverage. Familiarizing yourself with the details of your coverage may avoid misunderstandings later. Please give our staff your insurance information when you schedule your initial appointment. As a courtesy to you, prior to your appointment, our office will contact your insurance carrier to confirm what insurance benefits are available to you.
The requirements for benefits eligibility vary by policy. Some policies require a waiting period for new employees, while others may require a specific number of hours to be worked per pay period to remain eligible. Orthodontic coverage in some cases is available only to dependent children under the age of 19. If you are unsure of eligibility requirements, you should refer to the plan booklet or contact the insurance administrator at your place of business.
How Benefits are Calculated and Paid
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. If you change insurance providers or change jobs while in treatment, you may not receive the entire anticipated insurance benefit. It is common for orthodontic benefits to be paid at 50% of the treatment fee 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 your “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 or 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 your flexible benefits 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 that will be covered. The secondary carrier usually requires written confirmation from the primary carrier of the benefits to be covered.
How Our Orthodontic Office Can Help
Insurance benefits are coordinated between the insurance carrier and the insured. To assist you, we will gladly submit insurance claims and we accept most insurance benefit assignments.