All about insurance

Orthodontics can be pricy, but fortunately, there are all kinds of financing options and insurance benefits that can help. Insurance helps make orthodontic treatment possible for millions of people, but if you don’t know how to navigate the tricky waters, you could be missing out on certain benefits! Here are some of your top insurance questions, answered: 

Who should I talk to about my insurance?

Many orthodontic practices have their own trained professional on-site who can answer your insurance questions, and work with your provider as needed. At Amazing Smiles, Teresa is our Insurance Coordinator and would be happy to help you.

Will my orthodontist help me, or should I call my insurance company directly?

When you call to make your initial consultation, we will get your insurance information at that time. Our team will then call and verify your benefits prior to your appointment. No matter where you go, your orthodontic office should make sure you are fully informed of what your insurance will and will not cover before your appointment begins.

How will I know if my insurance covers it/what’s my co-pay? 

Co-pays and insurance breakdowns are a little bit different for everyone. We will get a complete orthodontic breakdown of your insurance coverage when we call to check your benefits.

How does insurance treat cosmetic vs. medically necessary orthodontics? 

Most insurance companies will extend orthodontic benefits to patients regardless of whether it’s cosmetic or medically necessary. However, there are a few insurance providers that will only extend benefits if they deem it medically necessary.  At Amazing Smiles, we submit a pre-authorization complete with a narrative from the doctor as well as photos and x-rays to the insurance prior to the patient starting treatment so you know what they will cover.

What’s HSA/FSA, and can I use mine on orthodontics?

HSA stands for “Health Savings Account” and FSA stands for “Flexible Spending Account”.  These are employer-based benefits to help with the extra costs that are not covered by insurance.   You can use both of these to help pay for braces.

What is a lifetime maximum? 

The lifetime maximum is an amount set by the insurance company as the maximum amount the plan will pay. Once you reach this maximum, insurance will no longer cover orthodontic procedures.

What if you have coverage from 2 insurance companies? Can you use both? 

In most cases, you can. Insurance companies use the “birthday rule,” meaning they use the birthday that comes first in the calendar year and that person’s coverage becomes the primary insurance. Typically, you receive the benefits from that insurance, while the secondary insurance pays at a certain percentage (usually 50 percent), up to the lifetime maximum. If there’s a “non-duplication clause,” the secondary insurance will not pay for duplicate benefits.

What if I get new insurance during the middle of treatment?

If you get new insurance during treatment, let us know so we can verify coverage and file the claim for you.

What happens if I change companies or lose my job?

Orthodontic benefits end if you change companies or lose your job. Any balance the insurance company did not pay will become your responsibility. We will work with you to get your balance paid in full, whether you are seeking new insurance or exploring a payment plan. If your new employer offers orthodontic insurance, we will file for benefits as soon as you are eligible.

What is a dental savings plan? 

Savings plans are not considered insurance, but for a fee, you get discounts on orthodontic services.  This is a good option to consider if you have dental insurance but no orthodontic coverage. It’s also a good option if you’ve used your lifetime max.  

How much will insurance cover? 

Orthodontic benefits aren’t like regular dental benefits. Most dental plans have an annual maximum that is renewed each year. Orthodontic benefits, on the other hand, are usually limited by lifetime maximums. Once you use these benefits, they’re gone and won’t be renewed. If you’re undergoing an orthodontic treatment that is completed in multiple phases, benefits used during the first phase will reduce the amount of coverage you can receive during the second phase. 

How do orthodontic benefits pay?  

Orthodontic benefits payout over the course of treatment, not in one lump sum payment. If your benefit is estimated at $3000, the Insurance Company generally pays an initial payment when the braces are placed and then monthly, quarterly, or annual installments for the remaining months of treatment. If the orthodontist estimates that you will be in braces for 2 years, you’ll want to make sure you keep your dental plan during those 2 years.  However, dropping your insurance before your benefit has finished paying can result in more out-of-pocket expenses for you.

What is a waiting period? 

Some dental plans require a waiting period before they will pay for braces. They might cover general dentistry immediately but sometimes will have you wait as long as 2 years before orthodontic coverage is active.

Don’t let the complicated world of insurance stop you from getting the smile of your dreams. Our team will be with you step by step to help you maximize your benefits and find a treatment plan that works for you. For more information, schedule your free consultation online or contact us today!

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