Can Insurance Cover Braces a Second Time?

Dental insurance helps manage costs for orthodontic treatment. While many plans offer some coverage for braces, understanding policy terms and limitations is necessary. Coverage for a second course of orthodontic treatment can differ significantly from initial care. Orthodontic benefits often operate distinctly from general dental coverage.

Understanding Policy Limitations for Orthodontic Coverage

Dental insurance plans often have specific orthodontic limitations. A primary restriction is the “lifetime maximum,” the total amount an insurance plan will pay for orthodontic treatment over an individual’s lifetime. This cap, commonly ranging from $1,000 to $3,000, applies per person and does not reset annually like standard dental maximums. Once this limit is reached, the individual becomes responsible for all remaining costs.

Another common limitation involves “age restrictions,” where many policies primarily cover orthodontic care for minors. Coverage for dependents often extends up to age 19, with some plans reaching age 26 if the individual remains on the parent’s plan. Adult orthodontic coverage is less common and typically includes more restrictions or lower benefit amounts, often requiring a premium or upgraded policy.

Many policies also include “waiting periods” before orthodontic benefits activate. These periods can range from six months to over a year, with some plans requiring up to two years of enrollment before coverage is available. Orthodontic treatment may not be covered immediately upon enrollment, even with an active policy. Insurance plans generally do not cover treatments considered purely cosmetic.

Criteria for Medically Necessary Orthodontic Retreatment

Insurance providers differentiate between cosmetic and “medically necessary” orthodontic treatment. Cosmetic adjustments are generally not covered, but treatment for functional or health-related issues may qualify. This distinction is important for a second course of treatment, as medical necessity can open pathways to coverage.

Conditions that often warrant medically necessary retreatment include:
Severe bite problems affecting chewing or speech, such as significant overjet (9 mm or more) or reverse overjet (3.5 mm or more).
Anterior or posterior crossbites affecting three or more teeth per arch.
Open bites of 2 mm or more across four or more teeth.
Impinging overbites causing soft tissue trauma.
Impacted teeth (excluding third molars).
Congenitally missing teeth.

Craniofacial abnormalities or systemic disorders affecting the dentition often fall under medical necessity. A federal definition of “medically necessary” does not exist; states often define their own criteria. Documentation from both dental and medical providers can help establish the need for treatment.

Verifying Your Insurance Benefits

Before pursuing a second course of orthodontic treatment, verify your specific insurance benefits. Begin by locating and reviewing your dental insurance policy documents, such as the benefit summary or plan booklet. Many insurance providers also offer online portals where you can access detailed information about your coverage.

Contacting your insurance provider’s customer service directly is also a practical step. When you call, be prepared to ask specific questions about orthodontic coverage for retreatment. Inquire about your lifetime maximum for orthodontics and whether any portion of it remains.

Ask if there are any age limitations for orthodontic coverage or if the policy contains any frequency clauses that might restrict a second treatment. Determine if pre-authorization is required for orthodontic treatment and what specific criteria for medically necessary orthodontics apply under your plan. Note down the names of representatives, dates, and reference numbers for all your communications.

The Pre-Authorization and Claims Process

Pre-authorization is often mandatory before beginning orthodontic treatment, especially for a second course. This involves your orthodontist submitting a proposed treatment plan to the insurance company. The submission typically includes X-rays, photographs, and a detailed letter explaining the medical necessity of the retreatment.

The insurance provider then reviews this documentation to determine if the proposed treatment meets their criteria for coverage. You can expect a response regarding approval or denial within a few business days to several weeks. Once pre-authorization is obtained, the claims submission process begins as treatment progresses.

Orthodontic claims are often submitted as a single claim at the time of initial banding, rather than for each monthly adjustment. This claim should include the banding date, the estimated treatment length, the total case fee, and relevant American Dental Association (ADA) procedure codes. If pre-authorization or a claim is denied, you typically have the right to appeal the decision by submitting additional information or a formal appeal letter to the insurer.