Braces: Insurance Coverage And Costs

Braces are a costly but common procedure, with around 4 million Americans wearing them at any given time. The average cost of traditional braces without insurance is between $5,000 and $6,000. However, dental insurance plans vary in their coverage of braces, and it's important to understand the specifics of your plan. Some plans may cover braces for children but not adults, and there may be age restrictions, with some plans only covering members under 19 or 26 years old. Additionally, orthodontic benefits typically have a lifetime out-of-pocket maximum, and there may be a waiting period for orthodontic coverage. When reviewing dental insurance plans, it's crucial to check the network of providers, coverage limits, and eligibility for discounts to make an informed decision.

Braces for children vs adults

Braces are devices that put steady pressure on the teeth, slowly moving them into a straighter position. They are used to correct bite problems and misaligned teeth in both children and adults. However, there are some key differences between braces for children and braces for adults.

One of the main differences is the speed of treatment. Children's bones are still developing and are more receptive to treatment, so results are achieved faster. Adult patients, on the other hand, can expect lengthier treatments as their bones are tougher and fully developed. The tissue around adult teeth has also settled, making it more challenging to realign them.

Another difference is the type of braces used. While traditional metal braces are the most common and affordable option for children, adults often prefer more discreet options such as ceramic braces or clear aligners like Invisalign. These options blend in with the teeth or are completely invisible, making them ideal for adults who want to avoid noticeable braces during professional commitments.

Additionally, children may be more inclined to choose mini brackets, while adults may opt for clear or ceramic brackets that are less noticeable. Children also tend to enjoy customising their metal braces with different colours, adding an element of fun to the process.

It is worth noting that the cost of braces for children is typically lower than for adults since less material is required to cover all their teeth. However, the number of appointments and the time spent in the dentist's chair are similar for both age groups, resulting in a minimal difference in overall cost.

In conclusion, while braces serve the same purpose for both children and adults, the treatment process and specific types of braces used can vary due to differences in bone development, aesthetic preferences, and cost considerations.

Medicaid coverage

Medicaid is a healthcare program administered by the government that aims to support individuals and families with low incomes. It provides comprehensive coverage for various medical services, including orthodontic treatment.

Medicaid covers a range of orthodontic procedures, providing assistance for eligible individuals to improve their dental health. Common procedures covered by Medicaid include braces and retainers. However, it's important to note that Medicaid does not extend coverage for orthodontic treatment for cosmetic purposes.

The application process for Medicaid orthodontic coverage typically involves the following steps:

• Determine if your state's Medicaid program includes an orthodontic benefit.
• Consult with a licensed orthodontist to assess your eligibility for Medicaid coverage.
• Identify and schedule treatment with an orthodontist who accepts Medicaid as a form of payment.

If your application for Medicaid orthodontic coverage is rejected, you have the right to appeal the decision. This process may include reviewing the denial letter, gathering supporting documentation, contacting your local Medicaid office, submitting an appeal letter, and awaiting a decision.

While Medicaid coverage for braces is generally geared towards children and adolescents, there may be exceptions for adults in certain states. Some states provide orthodontic coverage for adults when it is considered medically necessary, while others do not.

In summary, Medicaid coverage for braces varies across states and is typically limited to individuals under 21. The application process involves determining eligibility, consulting with an orthodontist, and identifying a Medicaid-approved treatment provider. Medicaid covers a range of orthodontic procedures but does not include cosmetic treatments. Adults seeking Medicaid coverage for braces may face varying levels of coverage depending on their state of residence.

Private insurance plans

When considering private insurance plans, there are several factors to keep in mind. Firstly, confirm that the plan provides orthodontic coverage. Full-coverage dental insurance plans often include orthodontic insurance, but this is not always the case. Secondly, review the dental plan's network of providers and orthodontists. Staying within the plan's network can help you save money. Thirdly, check for any coverage limits, such as maximum spending amounts, exclusions, or waiting periods for orthodontic services. Many plans have a lifetime maximum for orthodontic treatment. Finally, review your eligibility for orthodontic services discounts, as some plans may offer reduced rates for certain providers or treatments.

It is worth noting that orthodontic benefits typically have a lifetime out-of-pocket maximum instead of annual out-of-pocket maximums. Additionally, orthodontic insurance benefits often have age restrictions, limiting coverage to members under a certain age, such as 19 or 26 years old. Therefore, it is crucial to review the details of your private insurance plan to understand the extent of coverage for braces and any applicable restrictions or limitations.

When shopping for private insurance plans, it is important to compare the features and benefits to determine if braces are included and to pay attention to any limitations regarding braces coverage. For example, braces coverage may only apply to certain conditions or up to a specific age. By carefully reviewing the plan details and considering your specific needs, you can make an informed decision about the most suitable private insurance plan for your situation.

Dental insurance types

There are several types of dental insurance plans, each varying in terms of out-of-pocket costs, benefits, deductibles, and more. Some plans offer a wider network of dentists for a higher monthly premium, while others may be more affordable but restrict coverage for certain procedures or require more out-of-pocket spending on treatments. Here are some of the most common types of dental insurance plans:

Preferred Provider Organizations (PPO)

Dental Preferred Provider Organizations (PPO) plans offer a network of dentists who provide services for set fees. PPO plans typically offer stronger coverage for more expensive procedures like implants, braces, and surgery. They tend to have a broader network of dentists, and you may have the option to use your benefits out of the network as well. However, there is usually a benefit limit, after which you will be responsible for the full amount, although it will be at a discounted rate. PPO plans usually have deductibles and annual benefit limits, and they cover a percentage of each procedure based on its type and the plan's terms.

Dental Health Maintenance Organizations (DHMO)

Dental Health Maintenance Organizations (DHMO) plans provide lower-cost coverage with a focus on preventive care, including cleanings, periodic oral evaluations, x-rays, and sealants. DHMO plans require you to select a primary dental facility or dentist to manage and coordinate your oral health needs. They usually have no deductibles, and most preventive dental care is covered at 100%. However, they typically do not provide coverage if you choose to see dentists outside the network. DHMO plans may have yearly benefit limits and include copayments.

Indemnity Plans

Indemnity plans, also known as "traditional" insurance plans, allow patients to choose their own dentists and do not require the selection of a primary care dentist. The insurance company pays claims based on the procedures performed, usually as a percentage of the charges. Indemnity plans typically have an annual deductible and coinsurance, and patients pay for services out of their pocket until they meet the deductible. After that, the plan shares costs for covered services up to a certain limit.

Direct Reimbursement (DR) Plans

Direct Reimbursement (DR) plans require you to pay the bill upfront and then file a claim with the insurance company to receive reimbursement. Benefits in this type of plan are based on the amount spent rather than the type of treatment.

Point of Service (POS) Plans

Point of Service (POS) plans are arrangements where patients with a managed care dental plan can receive treatment from an out-of-network provider. The reimbursement for out-of-network services is usually based on a lower table of allowances, resulting in significantly reduced benefits compared to using an in-network provider.

Exclusive Provider Organizations (EPO) Plans

Exclusive Provider Organization (EPO) plans require subscribers to use only participating dentists to be reimbursed. These plans limit the choice of dentists and can severely restrict access to care.

Table or Schedule of Allowances Plans

Table or Schedule of Allowances plans are indemnity plans that pay a set dollar amount for each procedure, regardless of the actual charges. Patients are responsible for the difference between the carrier's payment and the charged fee.

Orthodontic services

• Standard metal braces are the most popular type of braces. Patients can choose different coloured elastic bands to personalise them.
• Braces with clear brackets function in the same way as traditional braces but are less noticeable.
• Clear aligners (such as Invisalign) are a set of custom-fitted trays that help straighten teeth. They are removable and less visible than braces.
• Retainers are used after braces to help keep teeth aligned and settled into their new position.

Orthodontic benefits are typically a subcategory of dental insurance but work a little differently. Orthodontic benefits usually have a lifetime out-of-pocket maximum instead of an annual one. When reviewing your dental plan for orthodontic benefits, check for any age restrictions. Orthodontic insurance benefits that are part of a dental package often have age limits, restricting benefits to members under 19 or 26.

Orthodontic treatments can be very expensive, and insurance can help reduce the financial burden. However, not all dental insurance plans include coverage for orthodontic services, so it is important to carefully read your plan materials. If you are in need of orthodontic services, you should review your plan to confirm that it provides orthodontic coverage, review the network of providers and orthodontists, check for any coverage limits, and learn if you are eligible for orthodontic services discounts.

Dental insurance plans that cover orthodontic treatments may include:

• Full-coverage dental insurance plans
• Employer-sponsored dental insurance plans
• Private individual and family plans
• Medicaid insurance programs (if braces are deemed medically necessary)

Frequently asked questions