How Insurance Can Help Pay For Braces?

Meet the Doctors at Colorado Orthodontics Using a HSA or FSA to Pay for Braces

Private insurance can be a very complicated issue, especially as it relates to orthodontic care. In this blog, we’ll try to break it down so that you can best know what your insurance may or may not cover and what to ask when choosing your dental plan at your next open enrollment.

First, a bit of a disclaimer that is important to understand when discussing dental insurance. EVERY PLAN IS DIFFERENT. Even as we discuss generalities of plans below, understand there can and always will be exceptions. We have seen some crazy stipulations in specific plans and at least once a month, having seen thousands of plans, we still find something that surprises us. Why are these plans all so different? Well, put simply, the insurance companies put forth a very wide range of options for your employer to chose from when selecting and forming a plan. Each of these options has pros and cons. Some will cost your company more money, but give you better coverage. Others may save them money, but place greater rules or restrictions on your coverage. Your employer creates the plans with the insurance company in a manner that best represents their desired balance between the coverage they’d like you to have and how much they are will to spend to provide it.

So, do all dental insurance plans cover orthodontics? No. Some plans do not have any orthodontics benefits. So while they may help pay to get your teeth cleaned, or a filling at the dentist, they will not cover any of the costs for braces, Invisalign, aligners, or any other type of orthodontic treatment. Other plans that DO have orthodontic benefits may have age limits on these benefits. For example they may cover your dependents up to a certain age (often this will be something like 19 or 25) but not cover you or your spouse. Additionally, if you get the coverage after braces are already on your (or your child’s) teeth, some plans will cover work in progress while others will not. These are all questions to ask your HR representative before signing up for a plan.

Why don’t all orthodontists and dentists accept every plan? The issue often has to do with contracted fee schedules. When a doctor agrees to accept specific insurance, they are also agreeing to only charge patients a specific amount dictated by the insurance company. A well known dental plan in this state, for example, has a standard contract across all providers that mandates that their insureds be charged no more than $5,205 for comprehensive orthodontic care or Invisalign. So, if you are an orthodontist who typically charges $8,000 for these services, you may choose not to join this network as it would force you to take a deep discount on your services. Alternatively, if you are a doctor that might normally charge $5,300 for these services (or less), you may be excited to join this network as you would be willing to accept the slight discount in return for the increased number of patients who would likely come to see you because you accept their insurance. These negotiated fee schedules can come more into play when it comes to certain discount plans and DHMOs which we will now explain.

Let’s now discuss the two main types of insurance plans: PPOs (Preferred Provider Organizations) and DHMOs (Dental Health Maintenance Organizations).

Typically, PPOs, if they have orthodontic benefits on the plan, will provide specific lifetime coverage for each of the insureds on the plan. These benefits will also have a percentage limit that the plan will plan for the total charges. This is best explained through a few examples. Let’s say (and this is the most typical coverage we see) that your plan provides $1,500 in orthodontic benefits paid at 50%. If the negotiated fee for braces is $5,200, the plan would pay $1,500 as long as you have the same insurance throughout the complete time of treatment. If, however, the care you are receiving was limited and so you were only charged $2,800, the plan would only pay $1,400 as this would hit the 50% limit set by the plan. Another example, if your child needed early, phase 1 care and you will billed $2,000 for this treatment, the plan would pay $1,000 of the $1,500 benefit. If years later you still had the same plan and your child needed phase 2 (comprehensive) care, the plan would only pay the remaining $500 of coverage as the plan’s benefits were stipulated as lifetime benefits. In any of these cases, as is with nearly all dental insurance, the benefits are paid out to the provider over the course of treatment. So if you lose coverage at any time during care, some of the charges you may have expected to be covered by insurance will be shifted back onto your account (you can, of course, provide a new insurance and, if it covers work in progress, it can be billed instead).
DHMOs can work much like a PPO, or they can work with co-pays associated with each procedure. If there are co-pays, the provider must calculate your coverage by assessing the difference between the co-pay and the contracted rates for each procedure. Often the number of months your care requires will also drive your coverage as DHMO benefits often involve a monthly care component to this calculation. Again, like a PPO, payments are made over time, so if you lose coverage, you may see charges shifted back to your account. One of the key benefits, and limitations of a DHMO to you, the insured, have to do with their contracted rates. Typically, most DMHOs offer greatly reduced contracted fee schedules relative to PPOs. While this is great for you in you can find an in-network provider that is of high quality (as it forces them to charge you a far lower fee for the service), the issue is that it greatly reduces the number of high-quality providers who are willing to work for these greatly reduced fees. So yes, you can save a lot of money, but you may have a hard time finding a good and highly reputable doctor who accepts your insurance (they do exist, however—our practice is proof positive of this!). Often there is also the trade-off that while the contracted rates are far more aggressive, the amount paid by the insurance company is often less than the typical PPO plan, so your net out of pocket expense may still be similar. But again, this can vary greatly and there are exceptions to every point noted here.

Separate from PPOs and DHMOs, there are discount plans. These plans, if accepted by your provider, will provide you greatly reduced contracted fees, but will not provide any additional benefits beyond these discounted prices.

What if mom and dad both have a child covered under their separate plans? In most cases, the good news is you CAN double-dip and receive benefits from both plans. The way this is calculated become very complex and varies a lot by the plan, but often is based on which plan is considered primary and which secondary. Believe it or not, the industry has generally used a rule-based on where on the calendar each parent’s birthday falls, with the parent having the earlier birthday considered as having the primary insurance.

So, is private dental insurance complicated? Yes, absolutely! Hopefully, this blog has helped shed a bit more light on dental insurance and how it works. You should also appreciate that the insurance team at your orthodontist’s and dentist’s office are working hard to help you get these benefits. We know we’ll get the same money, in the end, either way, but also appreciate that we have far happier patients that are willing to come back and refer their friends if we can help them get every penny for insurance that is possible. You should appreciate that if you are not getting the coverage you had hoped for or expected, that this is not typically the fault of your doctor’s team, but rather they are on your side to work and communicate with the insurance companies to help you try to receive greater coverage if at all possible.

Lastly, if you are here in the metro Denver area, we’d LOVE to see you! We openly take nearly ALL insurances (and to our knowledge are the only 5280 Top Orthodontist (and have been for 10 years!) and winner of the #1 practice in the state by Colorado Parent magazine that does so), and, while still a family-owned and operated practice, have 9 locations throughout the city to see patients. Just give one of our offices a call and schedule for a consultation.

We hope this all helps!

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Posted on May 21st, 2020

Posted in Uncategorized

How Insurance Can Help Pay For Braces?

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