Does Your Insurance Cover Braces a Second Time?

Orthodontic treatment helps many achieve improved dental health and alignment. While a first course of braces is common, understanding if insurance covers a second round involves complexities.

Initial Orthodontic Coverage Basics

Dental insurance plans often include specific benefits for orthodontic treatment, distinct from general dental care. These benefits typically operate under a “lifetime maximum,” which is the total amount the insurer will pay for orthodontic services over an individual’s lifetime, usually ranging from $1,000 to $3,000. This is a per-person limit and does not reset annually like other dental benefits.

Many policies also have age limitations, frequently covering dependents up to age 19, though some extend coverage to age 26 if they remain on the plan. Adult orthodontic coverage is less common and often comes with lower lifetime maximums, typically between $1,000 and $1,500. Insurance usually covers around 50% of the orthodontic treatment cost, up to the stated lifetime maximum.

New policies often impose waiting periods before orthodontic benefits become active, ranging from 6 to 24 months. Treatment started during this waiting period typically will not be covered, even after the period concludes.

Key Factors for Subsequent Braces Coverage

The primary determinant for insurance coverage of a second course of braces is the remaining balance of an individual’s orthodontic lifetime maximum. If the full lifetime maximum was utilized during initial treatment, no remaining benefits are generally available for subsequent treatment under the same policy.

Another significant factor is whether the second treatment is medically necessary rather than purely cosmetic. Insurance providers are more likely to cover re-treatment if it addresses functional issues, such as severe malocclusion, jaw misalignment, or difficulty chewing or speaking. Cosmetic adjustments are less likely to receive coverage. Some plans may even waive the lifetime maximum if the treatment is medically necessary.

Changes in insurance policies or switching providers can also influence coverage for a second round of braces. A new policy might offer a new lifetime maximum, especially if transitioning from a dependent plan to an adult plan. Verify if the new plan has specific clauses regarding pre-existing conditions or previously treated orthodontic issues. Adult orthodontic coverage is typically more restrictive and less common than coverage for children.

Steps to Determine and Secure Coverage

To begin the process of determining coverage for a second set of braces, thoroughly review your current dental insurance policy document. Focus on sections detailing orthodontic benefits, including any mention of lifetime maximums, age limits, and exclusions for re-treatment or cosmetic procedures.

Contacting your insurance provider directly is a necessary step to clarify your remaining benefits and policy specifics. Be prepared to ask targeted questions about coverage for a second orthodontic treatment, specifically inquiring about your remaining lifetime maximum and criteria for medical necessity. Document the date, time, and name of the representative you speak with, along with a summary of the conversation.

Following this, schedule a consultation with an orthodontist to obtain a professional diagnosis and a detailed treatment plan. If the orthodontist determines the treatment is medically necessary, ensure this is clearly documented in the treatment plan, as this supports your claim for coverage. The orthodontist’s office will typically provide a cost estimate for the proposed treatment.

Finally, initiate the pre-authorization or pre-determination process with your insurance company before starting any treatment. This involves submitting the orthodontist’s treatment plan and any supporting documentation, such as X-rays or diagnostic models, for the insurer to review. A pre-authorization confirms what the insurance company will cover, helping you understand your out-of-pocket expenses before committing to treatment.