Understanding Orthodontic Insurance: Billing Brace Treatments

Braces can be extremely expensive, with the average cost of traditional braces without insurance ranging from $5,000 to $6,000. Therefore, it is important to understand how to bill braces to insurance to reduce the financial burden. The process of billing braces to insurance can vary depending on the specific insurance plan and individual circumstances. In general, insurance coverage for braces is more common for children than for adults, with many plans considering braces as a form of orthodontic treatment under dental care. To increase the chances of getting braces covered by insurance, individuals should review their insurance plan, contact their insurance provider, verify medical necessity, find an in-network provider, understand financial responsibilities, and keep records and documentation. Additionally, it is crucial to be aware of different types of dental insurance plans, such as PPO, DHMO, indemnity plans, and direct reimbursement plans, as the coverage provided can differ significantly.

Braces may be covered by health insurance if they are deemed medically necessary

Braces can be extremely expensive, so it's important to know whether your insurance will cover the cost. The good news is that braces may be covered by health insurance if they are deemed medically necessary. Here are some key points to consider:

Medical Necessity

For insurance plans to cover braces, they often need to be deemed medically necessary. This means that the orthodontic treatment is required to correct significant functional or structural issues with the teeth or jaw. Examples of medical necessity include severe underbite or overbite, congenitally missing teeth, and craniofacial deformities.

Age Limitations

Insurance coverage for braces is generally more common for children than for adults. Many plans provide coverage for orthodontic treatment, including braces, for children under a certain age, typically up to 18 years old. Coverage for adults may be limited or excluded, and the list of medically necessary reasons for braces is shorter for adults.

Orthodontic Coverage

Some insurance plans include orthodontic coverage as part of their dental benefits. This may cover braces or other orthodontic appliances. However, this coverage may be subject to certain conditions, such as pre-authorization or a waiting period.

Supplemental Insurance

Individuals may have supplemental insurance plans that specifically cover orthodontic treatment, including braces. These plans may offer additional coverage or more flexible terms compared to regular dental insurance.

Choosing an In-Network Provider

Insurance plans typically have a network of preferred providers, including orthodontists, with whom they have negotiated contracts and discounted rates. Visiting an in-network orthodontist can result in greater coverage and cost savings compared to an out-of-network provider.

Understanding Financial Responsibilities

Even with insurance coverage, there may still be out-of-pocket expenses. It's important to understand any deductibles, co-pays, or coinsurance that you may be responsible for. Additionally, clarify the coverage percentage for braces and whether there are any limits or waiting periods.

Medicaid Coverage

Medicaid, a publicly-funded health insurance program for low-income individuals and families, often includes dental benefits that vary by state. Medicaid is the only health insurance that covers orthodontic braces without a medically necessary reason.

Alternative Options

If you cannot get insurance coverage for braces, there are alternative options to consider. Many orthodontic practices offer flexible payment plans or discounted fees for patients with financial constraints. Dental schools and residency programs often provide orthodontic treatment at lower costs. Additionally, charitable organizations may offer orthodontic assistance to those who cannot afford braces.

Medicare Part B covers braces when medically necessary and ordered by a Medicare-enrolled doctor

Medicare Part B covers braces when they are deemed medically necessary and are ordered by a Medicare-enrolled doctor or other healthcare provider. This includes braces for the arm, leg, back, and neck.

Medicare Part B classifies braces as durable medical equipment (DME), which is covered under the prefabricated orthotics benefit. To be covered by Medicare, a brace must meet specific DME criteria. It must be durable, with an expected lifetime of at least three years, and used for a medical reason. Additionally, the brace must not be useful to someone who is not sick or injured, and it must be used in the patient's home.

To get your brace covered by Medicare, you will need a prescription from a Medicare-approved physician. The supplier of the brace must also be enrolled in Medicare and accept assignment. If the supplier does not accept assignment, they can choose not to accept the Medicare-approved rate and may charge you more.

Even with Medicare coverage, you may still have out-of-pocket costs. After meeting the Part B deductible, you will typically pay 20% of the Medicare-approved amount for the brace. If you have a Medicare Advantage plan, your costs may vary depending on the specific plan you have chosen.

It is important to note that Medicare Part A and Part B have limited coverage for orthodontic care. However, if an accident or disease requires a restorative orthodontic procedure, it may be considered medically necessary and covered by Original Medicare. In the case of an emergency or surgical procedure requiring hospitalization, Medicare Part A may cover the associated hospital costs even if the orthodontic procedure itself is not covered.

If you are seeking expanded dental benefits, you may want to consider a Medicare Advantage Plan. These plans are offered by private insurance companies and typically include additional benefits like vision and dental care. However, even with a Medicare Advantage Plan, coverage for specialist care like braces may not be included, so it is essential to carefully review the list of benefits provided by each insurer.

If you have insurance, you will likely still need to pay for deductibles, co-insurance, and co-pays

Even if you have insurance, you will likely still need to pay for deductibles, co-insurance, and co-pays. These are important terms to understand when it comes to availing of health care insurance and schemes.

Deductibles

A deductible is a fixed amount of money that you have to pay before your insurance policy starts contributing to your medical treatment. The term for paying deductibles is decided by the insurance provider—it could be per year or per treatment. For example, if your policy mandates a deductible of Rs. 5000, you will be required to pay for your treatment expenditures amounting to Rs. 5000, after which your insurance policy will kick in.

Co-insurance

Co-insurance is the percentage of the bill you pay after you meet your deductible. It is the percentage of covered medical expenses you pay after you've met your deductible. Your health insurance plan pays the rest. For example, if you have an "80/20" plan, it means your plan covers 80% and you pay 20%—up until you reach your maximum out-of-pocket limit.

Co-pays

A co-pay, short for co-payment, is a fixed amount that a healthcare beneficiary pays for covered medical services. The remaining balance is covered by the person's insurance company. Co-pays are typically charged after a deductible has already been met. In some cases, though, co-pays are applied immediately.

The amount you pay towards your treatment is billed by your insurance provider, and you are required to pay them directly. Co-pays are typically lower for standard doctor visits than for seeing specialists. Co-pays for emergency room visits tend to be the highest.

Dental insurance is usually purchased separately from medical insurance

Dental insurance is typically offered in three ways: as part of an employer-sponsored health plan, as a self-purchased plan, or as a "rider" attached to a medical insurance policy. The separation between dental and medical insurance also exists because insurance carriers have complex systems that are tailored specifically to either dental or medical providers. Combining the two would require a significant overhaul of these systems and provider networks.

While dental and medical insurance are typically separate, some insurance plans do offer combined coverage. In the Marketplace, for example, health plans may include dental coverage, or separate dental plans can be purchased alongside a health plan. Additionally, Medicare Advantage Plans (Part C) may cover dental services for individuals aged 65 and older. However, these plans are not common, and dental insurance is usually purchased separately from medical insurance.

Dental insurance plans vary widely in what they cover, so it's important to review your specific plan

If your plan includes orthodontic coverage, there may be certain conditions attached, such as pre-authorization or a waiting period. Additionally, some plans may require a demonstration of medical necessity, such as significant functional or structural issues with your teeth or jaw, before covering orthodontic treatment.

It's worth noting that even if your dental insurance plan covers braces, it may not cover the full cost. You may be responsible for deductibles, co-pays, coinsurance, or annual maximums. Therefore, it's crucial to carefully review your specific insurance policy to understand the extent of coverage, any out-of-pocket costs, and any requirements or restrictions associated with your plan.

• Age restrictions: Check if there are any age limitations for orthodontic coverage. Some plans may provide coverage only for children, while others may extend it to adults as well.
• Coverage limits: Look for any maximum benefit or lifetime limits on orthodontic treatment. This indicates the maximum amount the insurance company will pay toward braces over your lifetime or a specific period.
• In-network vs. out-of-network: Understand the network restrictions of your plan. Visiting an in-network orthodontist often provides greater coverage and cost savings compared to an out-of-network provider.
• Deductibles and co-pays: Identify any deductibles and co-pays that you must pay before the coverage kicks in. These amounts can vary depending on your plan.
• Pre-authorization requirements: Check if pre-authorization or a referral from a primary care physician is required before starting orthodontic treatment.

By thoroughly reviewing your specific dental insurance plan, you can make informed decisions about your orthodontic care and financial responsibilities.

Frequently asked questions