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.
  • 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.
Posted on May 21st, 2020