Understanding Orthodontic Insurance Billing For Braces

Braces can cost thousands of dollars, but dental insurance can help cover some of the costs. The amount covered by insurance depends on the type of plan and the specific coverage offered. Some plans may only cover preventive care and partial restorative treatments, while others may have more extensive coverage. It's important to carefully review the coverage and limitations of a plan to determine if braces are covered and under what circumstances. Additionally, the cost of braces can vary depending on the type of braces, the patient's age, and the nature of the problem being treated. Metal braces, for example, tend to be less expensive than ceramic or invisible braces. When considering braces, it's essential to factor in the cost of additional expenses such as extra dental visits and teeth extractions.

Braces cost

The cost of braces varies depending on the type of braces, the complexity of the treatment, and insurance coverage. Traditional metal braces are typically the cheapest option, ranging from $3,000 to $7,000. Ceramic braces, which are less noticeable, usually cost between $4,000 and $8,000. Lingual braces, which are attached to the backs of the teeth, tend to be the most expensive, ranging from $8,000 to $12,000. Invisalign, a type of clear aligner, can cost anywhere from $3,500 to $9,500.

The cost of braces can also depend on the patient's age, the nature of the problem being treated, their location, and the recommended treatment plan. Braces for children can range from $1,100 to $7,000, while adult braces typically cost more. Braces in rural areas may be cheaper than in larger cities. The length of treatment can also impact the cost, with longer treatments requiring more visits to the orthodontist and potentially resulting in higher overall costs.

When considering the cost of braces, it's important to factor in additional expenses such as extra dental visits, teeth extractions, and special cleaning products. These can add up quickly, so it's crucial to have a clear understanding of what is and isn't covered by insurance.

Dental insurance can help cover the cost of braces, but the extent of coverage varies depending on the plan. Some plans may only cover a certain percentage of the cost, while others may have a specific dollar amount allocated for orthodontic treatments. There may also be restrictions based on age, with some plans only covering children or imposing higher costs for adults. It's essential to carefully review the terms of your insurance plan to determine what is covered and what out-of-pocket expenses you may incur.

To make braces more affordable, many orthodontists offer payment plans or discounts. Additionally, there are alternative funding options such as health savings accounts (HSAs) and flexible spending accounts (FSAs) that can be used to pay for braces. Shopping around for different orthodontists and comparing prices and services can also help in finding the best value.

Insurance coverage

The cost of braces can be high, so it is important to know what your insurance will and will not cover. The first step is to determine if your health insurance includes coverage for braces. If you have health insurance with a Flexible Spending Account (FSA) option, you may be eligible for reimbursement from the FSA for orthodontics. Similarly, if you are on a high-deductible health insurance plan, you can open a Health Savings Account (HSA) and invest tax-free money to use for most medical and dental bills.

If you don't have health insurance, or your health insurance does not cover braces, you can look into purchasing dental insurance. When shopping for dental insurance plans, compare the features and benefits to see if braces are included and pay special attention to any limitations regarding braces coverage. For example, it may only apply to braces that are needed for certain conditions or up to a specific age. Dental insurance is not required for children, and you won't face a penalty if you don't have it, but if you have children under the age of 18, insurance companies must offer you the option to purchase dental insurance that meets the criteria of the Affordable Care Act (ACA).

There are eight basic types of dental insurance, and it is important to know the differences when looking for coverage. Preferred Provider Organizations (PPO) plans offer a network of dentists who are covered by the insurance company to do dental work for set fees. Dental Health Maintenance Organizations (DHMO) plans give dentists a certain amount of money each month for each patient assigned to them, and they are then required to provide certain services at no cost or reduced cost. Indemnity plans are structured like traditional health insurance plans, with the insurance company paying claims based on the procedures performed, and usually allowing patients to choose their own doctors. Direct Reimbursement (DR) plans require you to pay the bill upfront and then file a claim with the insurance company to receive reimbursement. Point of Service (POS) plans are arrangements where patients with a managed care dental plan can receive treatment from an out-of-network provider, but benefits are significantly reduced. Discount or referral plans are not actually insurance plans, but rather give you a discount on dental services. Exclusive Provider Organizations (EPO) plans only allow patients to use participating dentists in order to be reimbursed, significantly limiting dentist choices. Finally, Table or Schedule of Allowances plans require users to pay a set amount for each procedure, with patients paying the difference between the fee and the carrier's payment.

Dental insurance plans typically cover preventative services, such as routine cleanings, exams, and bitewing X-rays; basic services, such as cavity fillings and simple tooth extractions; and major services, such as crowns, bridges, root canals, wisdom tooth extractions, periodontic deep cleanings, oral surgery, dentures, and partial dentures. Orthodontia, including braces and retainers, is also usually covered, but there are often restrictions. For example, braces must usually be deemed medically necessary, and most insurance companies won't cover braces for adults over the age of 18. There may also be a restriction that braces are only covered once in a lifetime.

If you are looking for a dental insurance plan that covers braces, it is recommended that you work with a broker who can help you shop for the best plan.

Payment options

Dental Insurance

Dental insurance can help cover the cost of braces, but it's not always a given. It's important to check with your insurance provider to see if your plan includes coverage for braces and, if so, what percentage of the cost is covered. Additionally, there may be a maximum benefit or lifetime limit on how much your insurance will pay for orthodontic treatment.

Flexible Spending Accounts (FSA) and Health Savings Accounts (HSA)

If you have an FSA or HSA, you can use those funds to pay for braces. These accounts offer tax advantages, allowing you to contribute pre-tax money that can be used for qualified medical and dental expenses.

Payment Plans

Many orthodontists offer payment plans, allowing you to pay for braces in instalments over a period of time. These plans may be interest-free, but be sure to understand the interest rates and compare them with other financing options.

Personal Loans and Credit Cards

Personal loans and credit cards can be used to finance braces, but be cautious of the interest rates, especially with credit cards, as they can add significantly to the overall cost.

Medicaid and Dental Charities

For low-income families, Medicaid may cover part of the cost of braces, especially if they are deemed medically necessary. Additionally, dental charities like Smiles Change Lives and Smiles for a Lifetime offer financing assistance for children between the ages of 10 and 18.

Discounts

Some orthodontists offer discounts for paying for braces upfront in full. This can be a significant saving, so it's worth inquiring about.

Dental Schools

Getting braces through a dental school can be a more affordable option, as residents provide the treatment under the supervision of experienced orthodontists. This option usually saves about a third of the cost of normal treatment.

Dental Discount Plans

Joining a dental discount plan can provide access to reduced costs for braces and other dental treatments. These plans typically involve paying an annual fee to gain access to a network of dentists and orthodontists who offer treatments at discounted rates.

Dental insurance types

There are several types of dental insurance plans, each with different out-of-pocket costs, benefits, deductibles, and more. Here are some of the most common types:

• Preferred Provider Organizations (PPOs): PPO plans are like health insurance in that they offer a network of dentists who are covered by the insurance company to perform dental work for set fees. PPOs tend to offer stronger coverage for more expensive procedures like implants, braces, and surgery. They usually have a benefit limit of $1,000 to $2,000, after which you're responsible for the entire amount. PPOs often have higher premiums than other plans, but they offer more flexibility in choosing a dentist or dental facility.
• Dental Health Maintenance Organizations (DHMOs): DHMO plans give dentists a certain amount of money each month for each patient assigned to them. In return, dentists must provide certain services at no cost or a reduced cost to those patients. DHMO plans typically have unlimited benefits but include a copay for all procedures. They also tend to have more restrictions and may lack coverage for higher-end procedures. DHMO plans usually have lower premiums than PPOs.
• Indemnity plans: Indemnity plans are the closest in structure to traditional health insurance plans. The insurance company pays claims based on the procedures performed and usually allows patients to choose their own doctors.
• Direct Reimbursement (DR) plans: These plans require you to pay the bill upfront and then file a claim with the insurance company to receive reimbursement.
• Point of Service (POS) plans: POS plans are arrangements where patients with a managed care dental plan can receive treatment from an out-of-network provider. The reimbursement to the patient is usually based on a low table of allowances, resulting in significantly reduced benefits compared to using an in-network provider.
• Discount or referral plans: These are not insurance plans but alternative types of plans that only give you a discount on dental services, like a coupon. You're still responsible for the full cost of the discounted bill.
• Exclusive Provider Organizations (EPOs): EPO plans require that subscribers use only participating dentists to be reimbursed. These plans significantly limit access to dentist choices and care.
• Table or Schedule of Allowances plans: These plans are indemnity plans that pay a set dollar amount for each procedure, irrespective of the actual charges. The patient is responsible for the difference between the carrier's payment and the charged fee.

Dental insurance exclusions

Dental insurance is an optional plan that can be purchased separately from medical insurance. It helps cover the cost of dental services for a monthly premium. However, it does not always work the same way as medical coverage, and there are several exclusions to what is covered.

Types of Exclusions

Dental insurance plans vary widely, but there are certain restrictions and limitations that are common. These include:

• Pre-existing conditions: Some dental plans do not cover dental conditions that existed before enrolling in the plan, such as missing teeth.
• Annual maximums: Many dental plans have a total annual dollar amount that they will pay during the plan year. If your dental costs exceed this limit, you will need to pay the amount above the limit out of pocket.
• Managed care cost containment measures: Dental benefit programs may have features designed to reduce or eliminate certain charges to the plan.
• Cosmetic procedures: Most dental insurance plans do not cover cosmetic or aesthetic procedures, such as tooth whitening.
• Experimental procedures: Dental insurance plans typically exclude coverage for experimental, investigational, or unproven procedures.
• Age restrictions: Most dental insurance plans have age restrictions for certain treatments, such as braces. For example, many plans restrict orthodontic coverage to patients under the age of 19.
• Specific treatments: Some dental insurance plans may only cover preventive care and partial restorative treatments, while others may offer more extensive coverage.
• Waiting periods: Some dental insurance plans have waiting periods before they will begin covering certain types of care, such as restorative or major dental work.

Choosing a Dental Plan

When choosing a dental insurance plan, it is important to consider the exclusions and limitations of the plan. Compare the features and benefits of different plans to determine if braces are included and if there are any limitations on braces coverage, such as age restrictions or specific conditions. Additionally, consider the monthly premiums, copayments, coinsurance, and deductibles associated with the plan.

Frequently asked questions