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Approximately 4 million people in the U.S. are wearing braces at any given time, and they aren’t just for kids [1] PDA Presents The Facts of Braces. Pennsylvania Dental Association. Accessed 6/8/2022. . In fact, one in three orthodontic patients is over the age of 18 [2] Why the Number of Adults Seeing an Orthodontist is at an All-Time High. American Association of Orthodontics. Accessed 6/8/2022. .
As common as they might be, braces—when not covered by dental insurance—can be quite expensive. The average cost of traditional braces without insurance is between $5,000 and $6,000. If you have dental insurance, however, or you’re considering enrolling in a plan, you might be wondering about orthodontic coverage specifically. Here’s everything you need to know about dental insurance and coverage for braces.
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Receive $80 Off Your Impression Kit With Code FORBESBBP Byte Teeth AlignersDental insurance is not typically part of medical insurance coverage. Instead, it’s usually an optional plan that can be purchased separately, and it doesn’t always work exactly the way medical coverage does.
Dental insurance is a policy that helps cover the cost of services administered in a dental office for a monthly premium similar to how you pay for medical insurance. “But it’s not insurance in the traditional sense,” explains Alex Karrenbrock, a sales associate at Apollo Insurance Group in Lees Summit, Missouri. “It’s a discount plan with a limited benefit. Meaning, if you go to a dentist that is in network, they’re contractually obligated to give you the discounted insurance fee and not the office fee, which is typically 20% to40% higher,” she says. Your dental insurance coverage helps to pay part or all of the fee—how much is paid depends on your specific plan and the benefits offered.
Even though dental insurance doesn’t always cover your entire bill, many people find it helpful when it comes to saving on preventative care and dental procedures that may be needed. Dental work can get very expensive very quickly, and insurance can often help alleviate that financial burden.
There are eight basic types of dental insurance, according to the American Dental Association (ADA). If you’re looking for coverage, knowing the differences is key.
Preferred Provider Organizations (PPO) plans are like health insurance in that they offer a network of dentists who are covered by the insurance company to do dental work for set fees. These plans generally offer stronger coverage for more expensive procedures like implants, braces and surgery, according to Yenile Pinto, D.D.S,. owner of Deering Dental in Miami. “PPOs also tend to have better doctors in their networks, and you typically have the option to use your benefits out of network as well,” she explains. “The downside of a PPO is that most plans have a $1,000 to $2,000 benefit, after which you’re responsible for paying the entire amount, though you pay the discounted insurance rate, which can save you up to 40%,” says Dr. Pinto.
Dental Health Maintenance Organizations (DHMO) plans give dentists a certain amount of money each month for each patient assigned to them. They are then required to provide certain services at no cost or reduced cost to those patients. “DHMO plans typically have unlimited benefits, but there is a copay for all procedures, and they tend to have more restrictions and lack coverage for higher-end procedures,” says Dr. Pinto. “Also, because reimbursements to the dentists are relatively low, many choose not to participate in DHMOs, which can limit your access to better and more experienced providers.”
Indemnity plans are the closest in structure to a traditional health insurance plan. The insurance company pays claims based on the procedures performed and usually allows patients to choose their own doctors. “This policy pays the dentist a percentage of the bill on your behalf according to the plan’s guidelines,” explains Karrenbrock.
Direct Reimbursement (DR) plans are exactly what they sound like: “These types of plans require you to pay the bill up front and then file a claim with the insurance company to receive a reimbursement check in the mail later,” says Karrenbrock.
Point of Service (POS) plans are arrangements where patients who have a managed care dental plan can receive treatment from an out-of-network provider. The patient is typically reimbursed, but benefits are reduced significantly compared to what they would be if the patient saw a provider who was in network.
Discount or referral plans technically aren’t insurance plans: “There are alternative types of plans called discount dental plans that only give you a discount on dental services—like a coupon at the grocery store,” explains Karrenbrock. “But you’re still responsible for the full cost of the discounted bill.”
Exclusive Provider Organizations (EPO) plans only allow patients to use participating dentists in order to be reimbursed. Because of that restriction, these plans significantly limit access to dentist choices and care.
Table or Schedule of Allowances plans require users to pay a set amount for each procedure. Patients must pay the difference between the fee and the carrier’s payment.
Because there are so many different types of dental plans, what your insurance covers depends on the type of plan you have. “I’ve seen plans that have coverage ranging from almost nothing beyond preventative care and others that have unlimited benefits and cover nearly any treatment you might need,” says Dr. Pinto. “It’s best to speak with your insurance carrier or human resources department [if you have an employer-provided plan] to better understand your plan’s benefits.”
With that said, Karrenbrock notes that dental insurance plans typically cover:
There are almost always limitations and exclusions on a dental policy, so it’s something to review before you purchase a plan. “For instance, all dental policies have a missing tooth clause, which means if the tooth is missing before you get the plan, the insurance company will not pay to have the tooth replaced,” says Karrenbrock. “Most plans don’t cover implants or braces for adults. Also, most plans have waiting periods, which means certain procedures won’t be covered until after a specific amount of time has lapsed.” Elective or cosmetic dental work is almost never covered by dental insurance.
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A lot of dental insurance plans do cover braces, but there are caveats and important details to consider. Karrenbrock notes that you have to choose a plan that does cover braces, but even then, he says they must be deemed medically necessary.
There are other restrictions to orthodontia coverage as well. “A common restriction is that braces are only covered once in a lifetime, so if you had braces in the past and need them again because you didn’t wear your retainer, they won’t be covered,” says Dr. Pinto. That restriction applies even if you get a new insurance plan with a new job if the plan is provided by the same insurance company. Age is the other big restriction. Karrenbrock notes that for most dental insurance plans, you must be under 18 years old, but Dr. Pinto says some won’t cover braces for anyone over 16 years old.
According to Karrenbrock, Medicare generally doesn’t pay for dental bills. “Most people with Medicare coverage pick up a separate dental insurance plan,” he says.
Karrenbrock says while funds in health savings accounts (HSAs) and flexible spending accounts (FSAs) can be used to pay for dental bills, it doesn’t make a difference in price. “You would just get the tax benefits associated with the HSA/FSA account,” he adds.
Alternatives to braces typically include treatments like Invisalign, retainers, headgear and veneers. Some dental insurance plans cover them, although your out-of-pocket cost might be more than what you pay for other services. “Treatments like Invisalign are still covered but are considered upgraded services in many cases,” says Dr. Pinto. “If you choose to do Invisalign, it’s understood that you’re choosing a premium service—not the standard braces that your insurance covers—so you will be responsible for the difference between what your doctor charges for Invisalign and what your insurance provider pays.”
To find the right dental insurance plan for you, Karrenbrock recommends working with a broker who can help you shop for the best plan. “In general, you should look for a plan that covers ‘orthodontia’ and look into the limitations or exclusions associated with the plan,” he says.
Costs associated with dental insurance can add up quickly, but remember that paying for it monthly might end up saving you money in the long run if you end up needing a major procedure or braces. That said, here are a few tips to consider when shopping around:
“These membership plans were unheard of a few years ago but have become much more commonplace and can be a great option,” she says. Just remember these plans limit you to receiving care at that one dental practice.