Which Dental Insurance Plans Cover Braces?

Dental insurance helps manage the financial aspects of oral healthcare. It is a contract where a carrier agrees to pay a portion of covered dental services. While dental insurance covers routine cleanings and exams, coverage for orthodontic treatments like braces can be complex due to significant plan variations. Understanding these policies is important for individuals seeking orthodontic care.

Understanding Orthodontic Coverage

Orthodontic coverage within dental insurance plans is often distinct from general dental benefits. Many dental plans do not include comprehensive orthodontic coverage, and those that do frequently impose specific limitations. Standard dental insurance categorizes procedures into preventive, basic, and major, with varying coverage percentages.

Orthodontic treatments, such as braces, typically fall under a separate benefit category due to their specialized nature and higher costs. Adult orthodontic coverage is less common and, if available, may come with higher premiums or more limited benefits. While some plans may cover traditional metal braces, coverage for other types like ceramic braces or clear aligners can vary or be excluded.

Types of Dental Insurance Plans

Various types of dental insurance plans exist, each with different structures for orthodontic coverage.

Preferred Provider Organization (PPO) plans offer flexibility in choosing dental professionals and often cover a percentage of orthodontic costs after a deductible. PPO plans allow policyholders to use out-of-network providers, though at a higher out-of-pocket cost.

Dental Health Maintenance Organization (DHMO) plans require individuals to select a primary dentist within a specific network. Orthodontic coverage under DHMO plans can be more restrictive, often necessitating referrals and limiting choices to in-network orthodontists.

Discount plans are not insurance policies but provide reduced rates for services from participating dental professionals, including orthodontists. These plans usually do not involve claims submissions, deductibles, or co-insurance for orthodontic care.

Some insurers also offer stand-alone orthodontic plans or riders that can be added to existing dental policies to provide specific benefits for orthodontic treatment.

Key Policy Details

Dental insurance policies with orthodontic coverage include specific terms and limitations that affect benefits:

Waiting periods are common, typically 6 to 24 months, before orthodontic benefits become active.
Deductibles are the amount a policyholder must pay out-of-pocket before the insurance plan contributes to costs.
Co-insurance or coverage percentages dictate the portion of costs the plan covers after the deductible is satisfied, with orthodontics often covered at around 50%.
Most plans also impose a lifetime maximum, the total dollar amount the insurance will pay for orthodontic treatment over the policyholder’s lifetime. These maximums commonly range from $1,000 to $3,000 per person.
Age limitations frequently apply, with many plans covering orthodontics primarily for dependents up to age 19.
Pre-authorization or pre-treatment estimates are often required, meaning the insurance company needs to approve the treatment plan and estimated costs before treatment begins for benefits to be paid.
Some plans may also require that orthodontic treatment be deemed “medically necessary” rather than purely cosmetic for coverage to apply.

Steps to Find Coverage

Finding a dental insurance plan that includes orthodontic coverage involves several steps.

Individuals should first assess their specific orthodontic needs, considering whether treatment is for a child or an adult and the anticipated complexity.

Review any existing dental insurance policies or employer-sponsored benefits to determine current coverage details.

Research online using comparison tools, insurance brokers, or by visiting provider websites.

When contacting insurers, ask specific questions about orthodontic benefits, such as age group coverage, waiting periods, lifetime maximums, and network orthodontists.

Before enrolling, thoroughly review the Summary of Benefits and Coverage or the complete policy booklet to understand all terms and conditions.

Accessing Your Benefits

Once a dental insurance plan with orthodontic coverage is in place and treatment is needed, specific procedures must be followed to access benefits.

Obtaining a pre-treatment estimate from the orthodontist is a common first step. This estimate is then submitted to the insurance company for pre-authorization, which helps confirm coverage and estimated benefits.

The pre-treatment estimate will clarify the policyholder’s financial responsibility.

Many orthodontic offices assist with claims submission, streamlining the process for patients. They may also offer payment plans for the portion of costs not covered by insurance.

If an individual has more than one dental insurance plan, coordination of benefits rules will determine how the plans work together to cover the treatment.