Common Questions Regarding Orthodontic Benefits
Does a dental plan include orthodontic coverage as well?
No, dental benefits and orthodontic benefits are distinct.
Do I have to file my insurance claim?
Insurance coding can be tricky, so we will cheerfully file all insurance claims and follow-ups as a courtesy to our patients.
How does the insurance company pay?
Most insurance companies make an initial "down payment," followed by either monthly or quarterly payments over the course of treatment.
When will my insurance claim be filed?
Claims are filed on or after the "start date." This is when appliances, such as braces or Invisalign trays, have been "delivered/inserted." If you think you will be switching to new orthodontic coverage, it may be beneficial to hold off on treatment (see "work in progress" clause). Dr. Wirant can help you make that decision if it isn't adverse to treatment.
What happens if I get new insurance during treatment?
If you get new insurance during treatment, just let us know, and we will get it verified and filed for you. In most cases, you will not receive the insurance "down payment,” but you will receive the monthly payments from the effective date through your retention (retainer checkups).
What if my children are covered under two insurances? Can I use both?
In most cases, yes, you can. Insurance companies use the "birthday rule," which means they use the parent’s birthday that comes first in the calendar year. That insurance becomes the "primary insurance." The benefits from the "primary insurance" you are sure to obtain. The "secondary insurance" will pay at a certain percentage (usually 50%) up to the lifetime maximum. If there is a "non-duplication clause," this means that the secondary insurance will not pay.
What is a lifetime max?
Set by the insurance company, the lifetime max is the total amount that they will pay towards orthodontics and is a one-time benefit versus an annual-type benefit. The lifetime max can vary between $750 and $2500. Benefits through age 19—and up to age 23 if the patient is a full-time student—are per family member. Most adults are not covered. Some lifetime max benefits are paid at a percentage (usually 50%) based on the overall treatment fee.
Can I use my insurance as my down payment or to pay my account?
No. Each responsible party (insurance company and patient) has a separate account. Insurance billing is different and separate from the patient billing (prorated/proration).
What happens if I change companies or lose my job?
If you lose your job or change companies, the orthodontic benefits will be "terminated" on that day. Any balance that the insurance company did not pay will become your responsibility. In either case, we will work with you under your particular situation to help you get your balance paid in full. If your new employer offers orthodontic insurance, we will file for benefits as soon as you become eligible.
What is a "work in progress" clause?
A work in progress clause states that, if treatment has already begun, the patient is not eligible for benefits. This is something to watch for if you change jobs. You can ask your employer’s human resources manager, or you may find the information in your employee handbook. This covers some of the most frequently asked questions about orthodontic insurance. Please call Beth for any further questions.