Does Military Insurance Cover Braces?
Are braces covered by military insurance? This guide clarifies coverage, eligibility, and navigating orthodontic care for military families.
Military families seeking orthodontic care often wonder if military insurance covers braces. The answer involves understanding various plans, eligibility criteria, and specific coverage details. This is due to the different dental programs available to service members and their families, each with distinct rules and limitations for orthodontic benefits.
Military Dental and Orthodontic Insurance Programs
Dental care for military personnel and their families is primarily managed through two distinct programs: the TRICARE Dental Program (TDP) and the Federal Employees Dental and Vision Insurance Program (FEDVIP). These programs aim to provide access to dental services, including potential orthodontic benefits.
The TRICARE Dental Program is specifically designed for active duty family members, as well as certain National Guard and Reserve members and their families. This program requires separate enrollment, unlike TRICARE’s automatic medical coverage. United Concordia administers the TDP, which serves as a dental insurance option for eligible beneficiaries.
In contrast, the Federal Employees Dental and Vision Insurance Program (FEDVIP) extends dental coverage to a broader group, including retired service members and their families, federal employees, and survivor annuitants. FEDVIP offers a selection of commercial dental plans from various carriers, such as MetLife, Aetna, United Concordia, Delta Dental, and GEHA, providing flexibility in choosing a plan that aligns with individual needs. Orthodontic coverage under FEDVIP varies significantly by the specific plan selected.
Eligibility for Orthodontic Coverage
Eligibility for orthodontic benefits depends on military status and dependent age. For active duty service members, orthodontic treatment is limited to severe cases affecting their health or duty performance. Approval is only granted if essential for military readiness or due to recent trauma.
For TRICARE Dental Program enrollees, orthodontic coverage is available for children up to age 21, or up to age 23 if full-time students. Spouses and National Guard/Reserve sponsors are also eligible for coverage up to age 23. Retirees do not have access to TDP and instead utilize FEDVIP for their dental insurance needs.
Specifics of Orthodontic Coverage
Orthodontic coverage under military dental plans, especially the TRICARE Dental Program, requires “medical necessity.” This means treatment must address a health issue, not just cosmetic concerns. While TRICARE covers orthodontia only for severe congenital abnormalities like a cleft palate, the TRICARE Dental Program offers broader coverage for medically necessary care.
The TRICARE Dental Program has a lifetime maximum benefit of $1,750 per person. It covers 50% of allowed charges for orthodontic services, with the beneficiary responsible for the remaining 50% as a cost-share. Any costs exceeding the $1,750 maximum are the beneficiary’s full responsibility. FEDVIP dental plans offer varying orthodontic benefits, with some covering about 50% up to $2,000, though this varies by plan. Some FEDVIP plans also have no waiting periods for major services.
Traditional metal and ceramic braces are covered if medically necessary. Clear aligners, such as Invisalign, are also covered by the TRICARE Dental Program, at 50% of the cost up to the $1,750 lifetime maximum. However, Invisalign coverage for active duty members may be limited and often does not qualify for military discounts if categorized as cosmetic. Conditions requiring orthodontic treatment for medical necessity include overbites, underbites, crossbites, spacing issues, and crowding.
Navigating Orthodontic Treatment and Claims
To use military dental insurance for orthodontic treatment, first find an in-network provider using your plan’s online directory. Using non-network providers can result in higher out-of-pocket costs. For example, with the TRICARE Dental Program, a non-network provider means you pay the 50% cost-share plus the difference between the plan’s allowance and the billed charges.
Before starting orthodontic treatment, obtain pre-authorization (also known as a pre-treatment estimate) from your insurance plan. This process confirms coverage and estimates the costs you will owe. Active duty service members may also need command authorization. Pre-authorization is mandatory for certain complex or costly procedures; failure to obtain it could result in full beneficiary responsibility.
After treatment, claims submission is necessary for the insurance plan to process payments. Orthodontic providers often submit claims directly, but beneficiaries should be prepared to submit them, especially if using an out-of-network provider. After a claim is processed, beneficiaries receive an Explanation of Benefits (EOB) statement. This document details the services received, the amount billed, the amount covered by the plan, and any remaining balance owed by the beneficiary. Reviewing the EOB is important to ensure accuracy and understand the financial responsibilities.