How to Get Insurance to Cover Braces

Braces address misaligned teeth and bite issues, offering aesthetic and health benefits. Orthodontic treatment can be costly, prompting many to seek insurance coverage. This article guides readers through understanding, verifying, and utilizing insurance benefits for braces.

Understanding Insurance Coverage for Braces

Insurance for orthodontic treatment primarily comes from dental insurance. Some dental plans include this benefit, while others require an orthodontic rider or separate benefits. Coverage often ranges from 25% to 50% of the cost.

Medical insurance may cover braces if treatment is medically necessary, not purely cosmetic. This includes severe malocclusion, jaw problems, breathing difficulties, speech impediments from misaligned teeth, or congenital defects. Insurers require detailed documentation and a referral from a dentist or orthodontist.

Key insurance terms influence orthodontic coverage:
Annual Maximum: The highest amount an insurer pays for general dental services in a 12-month period, typically $1,000 to $2,000, resetting annually.
Lifetime Maximum: The total amount an insurer pays for orthodontic treatment over the policy’s duration, often $1,000 to $3,000. This benefit does not reset yearly.
Deductible: The out-of-pocket amount paid before insurance covers costs.
Co-insurance/Co-payment: The percentage or fixed amount you pay after meeting your deductible; for orthodontics, this is commonly 50%.
Waiting Periods: Require enrollment for a certain duration, from months to over a year, before orthodontic benefits activate.

Checking Your Existing Insurance Policy

To determine your orthodontic benefits, locate your insurance policy documents. Most providers offer access through online portals, where you can find a Summary of Benefits and Coverage (SBC). Reviewing these documents provides initial insights into coverage and limitations.

Contact your insurance provider directly for clarification. The customer service number is on your insurance identification card or the company’s website. A representative can provide specific details about your plan’s orthodontic coverage.

When speaking with the insurance representative, ask:
Does your plan cover orthodontics for both adults and children?
What is the orthodontic lifetime maximum benefit?
Is there a deductible or co-insurance for orthodontic services?
Are there any waiting periods before benefits become available?
Is pre-authorization required for treatment?
Which types of braces, such as traditional metal braces or clear aligners, are covered?
If your insurance is employer-provided, contact your human resources department for benefit summaries.

Navigating the Orthodontic Insurance Process

After confirming coverage, obtain pre-authorization, also known as pre-determination or a pre-treatment estimate. The orthodontist’s office submits a proposed treatment plan to your insurer. The insurer reviews it and provides an estimate of coverage. While not a payment guarantee, this estimate clarifies your expected out-of-pocket costs.

The orthodontist’s office manages insurance claims. Most practices have staff dedicated to working with insurance companies, submitting claims, and helping patients understand benefits. Claims are typically submitted electronically, streamlining the process.

After treatment, you will receive an Explanation of Benefits (EOB) from your insurance company. This statement outlines services provided, what the insurer covered, and your remaining balance. An EOB is not a bill.

Review the EOB for accuracy, comparing it against services received and orthodontist bills. If you find discrepancies or a denied claim, understand the reason in the denial notice. You may need to gather supporting documentation, such as clinical notes or X-rays, and submit an appeal within the specified deadline. Contacting your insurer directly can help resolve issues.

Insurance typically pays the lifetime benefit in installments over the course of treatment. The plan must remain active for the duration of treatment to receive the full benefit.

Exploring Alternatives for Coverage

If existing insurance coverage for braces is insufficient, several alternatives can help manage costs. Flexible Spending Accounts (FSAs) and Health Savings Accounts (HSAs) offer a tax-advantaged way to pay for qualified medical expenses, including orthodontics. Funds are pre-tax. FSAs generally have a “use-it-or-lose-it” policy, while HSA balances typically roll over annually. Eligibility for an HSA requires enrollment in a high-deductible health plan.

Many orthodontic practices offer in-house payment plans, allowing monthly installments instead of an upfront sum. These plans often feature interest-free terms and may require a down payment. Third-party financing options also provide extended payment periods, though these may involve interest rates based on credit approval.

Dental discount plans involve an annual membership fee and provide reduced rates, often saving members between 15% and 50% with participating providers. Unlike insurance, discount plans typically have no waiting periods or deductibles.

New insurance policies or riders specifically for orthodontics are another option, though these may have waiting periods before benefits activate.

Some dental schools and community dental clinics offer reduced-cost orthodontic treatment, often performed by students under professional supervision. Medicaid may also cover medically necessary orthodontic treatment for children in certain situations, depending on state guidelines.