When it comes to dental care, many patients are familiar with the fact that their dental insurance can help cover routine visits, cleanings, and treatments. However, when it comes to more specialized services like orthodontics, questions often arise. Orthodontic treatments, such as braces or Invisalign, are a significant investment, and many patients wonder if their dental insurance will cover these services. The answer isn’t always straightforward, as coverage can depend on several factors, including the specifics of the dental plan, the patient’s age, and the type of orthodontic treatment needed.
In this article, we will dive deep into whether dental insurance can be used for orthodontic care. We’ll also explore what typically is covered, what isn’t, and the options available to those seeking orthodontic treatments. Understanding how dental insurance works in relation to orthodontics will help you make more informed decisions about your dental care and finances.
What is Orthodontic Care?
Types of Orthodontic Treatments
Orthodontics is a branch of dentistry that deals with the correction of misaligned teeth and jaws. The goal of orthodontic care is to improve both the function and appearance of the teeth and mouth. Common orthodontic treatments include:
- Braces: The most traditional form of orthodontics, braces use brackets and wires to straighten teeth.
- Invisalign: A modern alternative to braces, Invisalign uses clear plastic aligners to gradually shift teeth into place.
- Retainers: After orthodontic treatment, retainers are used to keep teeth in their new positions.
- Palatal Expanders: These are used to widen the upper jaw in patients who have a narrow palate.
The Importance of Orthodontics
Orthodontic care is often considered a cosmetic treatment, but it can also improve a person’s oral health. Misaligned teeth can lead to difficulty cleaning the teeth properly, which increases the risk of cavities and gum disease. Crooked teeth or bite issues can also cause problems with chewing, speaking, and even breathing. Therefore, orthodontics isn’t just about achieving a beautiful smile; it’s also about improving overall oral health and function.
Does Dental Insurance Cover Orthodontics?
Standard Dental Insurance Coverage
Most traditional dental insurance plans cover basic dental services like cleanings, checkups, fillings, and sometimes even major treatments like crowns or root canals. However, orthodontics falls into a different category. While some dental insurance plans offer orthodontic coverage, it’s not guaranteed, and the specifics can vary significantly from one plan to another.
Coverage for Children vs. Adults
For many people, orthodontic treatments are associated with childhood or adolescence, and for good reason. The American Association of Orthodontists recommends that children have an initial orthodontic evaluation by the age of seven. Since many dental insurance plans prioritize coverage for children, you may find that orthodontic treatment for minors is more likely to be covered.
Adult orthodontics, on the other hand, is often treated differently by dental insurance companies. While it is certainly possible to use dental insurance for adult orthodontics, many insurance plans provide more limited coverage or none at all for adults seeking braces or clear aligners.
Types of Insurance Plans That May Cover Orthodontics
Not all dental insurance plans are the same, and the level of coverage for orthodontic treatments can vary based on the specific plan. Here are a few types of plans that may provide coverage for orthodontics:
PPO (Preferred Provider Organization) Plans: These plans typically offer more flexibility in choosing providers. Some PPO plans include orthodontic benefits, especially for children. However, the amount of coverage can vary, and there may be limitations on how much the insurance will pay for orthodontic care.
DHMO (Dental Health Maintenance Organization) Plans: These plans often have a more limited network of providers and may require referrals. Some DHMO plans provide orthodontic coverage, but the coverage could be more restricted and less comprehensive compared to PPO plans.
Indemnity Plans: These are traditional dental insurance plans that allow you to visit any dentist you choose. Some indemnity plans do cover orthodontics, but this typically comes with higher premiums or out-of-pocket costs.
Discount or Savings Plans: While not traditional insurance, some patients use dental savings plans or discount programs, which may offer reduced rates on orthodontic treatments. These programs often provide discounts, but they do not offer the same coverage as traditional insurance.
What is Typically Covered?
Orthodontic coverage varies, but in many cases, dental insurance plans that include orthodontic benefits will cover a portion of the treatment costs. Here is what you can typically expect:
Coverage for Children: Most plans that cover orthodontics will pay a percentage of the total cost for children under a certain age. Commonly, dental insurance for children covers around 50% of the costs for braces or other treatments, with the remaining balance paid by the patient.
Lifetime Maximum: Insurance plans often have a lifetime maximum benefit for orthodontic treatments, which is the maximum amount the plan will pay out for orthodontic care throughout a person’s life. This maximum typically ranges from $1,000 to $2,000.
In-Network vs. Out-of-Network: If you go to an in-network orthodontist, you are likely to pay less because your insurance has pre-negotiated rates with these providers. However, if you choose an out-of-network orthodontist, you may need to pay a higher percentage of the costs or even cover the entire cost upfront and submit a claim for reimbursement.
What Is Not Covered?
While some dental insurance plans do cover orthodontic treatments, there are several aspects that often are not covered:
Cosmetic Treatments: If your orthodontic treatment is deemed cosmetic or elective (i.e., not medically necessary), many insurance plans will not cover the costs. For instance, if you choose to get Invisalign to improve the aesthetics of your smile but don’t have a functional problem, the treatment may not be covered.
Adult Orthodontics: As mentioned earlier, many dental insurance policies limit or exclude coverage for adult orthodontics. Some plans will only offer partial coverage for adult braces or aligners, or they may not cover the treatment at all.
Post-Treatment Retainers: Retainers are usually necessary after braces or aligners, but some plans do not cover the cost of retainers. Even if they do cover them, it’s often under the lifetime maximum benefit for orthodontics, so you may need to pay out-of-pocket for these devices.
Alternatives to Dental Insurance for Orthodontics
Financing Options
If your dental insurance does not fully cover the cost of orthodontic treatments, many orthodontists offer financing plans. These plans allow you to make monthly payments over time, which can make the cost of treatment more manageable. Some orthodontists even work with third-party lenders to offer 0% financing for patients who qualify.
Health Savings Accounts (HSAs) and Flexible Spending Accounts (FSAs)
If you have a Health Savings Account (HSA) or a Flexible Spending Account (FSA), you may be able to use these funds to pay for orthodontic treatments. These accounts allow you to save money tax-free for medical expenses, including dental care. You can use these funds to pay for orthodontic services, potentially reducing your out-of-pocket costs.
Medicaid and CHIP
In some cases, Medicaid or the Children’s Health Insurance Program (CHIP) may cover orthodontic care for eligible individuals, especially if the treatment is considered medically necessary. Medicaid coverage varies by state, so it’s important to check with your specific state’s program to see if orthodontics is covered.
How to Maximize Your Orthodontic Benefits
Review Your Insurance Policy
The best way to understand what is covered is to carefully review your dental insurance policy. Check for any exclusions or limitations on orthodontic care, and take note of the lifetime maximum benefit and how it applies to children and adults.
Get a Pre-Treatment Estimate
Before starting treatment, request a pre-treatment estimate from your orthodontist. This will provide a clear breakdown of the costs involved and show what your insurance is likely to cover. This will help you plan financially and avoid unexpected expenses.
Consider a Payment Plan
If your dental insurance does not cover the full cost of orthodontics, ask your orthodontist about payment plans or financing options. These can help you spread out the cost over time, making it easier to afford treatment.
Conclusion
In conclusion, while dental insurance can often cover some orthodontic treatments, the level of coverage depends on the specifics of your insurance plan. Most insurance plans offer coverage for children’s orthodontics, but coverage for adults is more limited. It is important to carefully review your insurance policy, consider alternative payment options like financing or HSAs, and speak with your orthodontist about how to best manage the cost of your treatment. With the right approach, you can make your orthodontic care more affordable and accessible.
Related topics:
Is There a Maximum Benefit for Dental Insurance?
What Happens If I Miss a Dental Insurance Payment?
Can Dental Insurance Help with Dentures?
