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Understanding Your Orthodontic Insurance

October 22nd, 2020

Understanding Your Orthodontic Insurance
Orthodontic insurance is very different from medical insurance! Our insurance specialists here at Green Orthodontics have gathered up some common questions about navigating orthodontic insurance. If you have any questions that were not discussed in this blog, please feel free to call us at 931-542-9940 any time and a friendly insurance specialist will be glad to assist!

Do You Accept My Insurance?
Green Orthodontics accepts ALL insurances! We can verify your insurance prior to the consultation to ensure we are maximizing benefits.

Do I Have to Have Insurance to Schedule a Consultation?
Nope! Patients are not required to have insurance in order to be seen. We offer 100% complimentary consultations. There are no charges for this visit and even the x-rays are free!

What is a DPO or HMO insurance?
In some rare cases, a workplace may be contracted out with specific orthodontists within a certain radius. In this case, even though we accept payments from the main insurance company, the “group” may not be willing to pay benefits. If you have an insurance policy like this, we encourage you to contact your insurance company for more information on specific coverage. You are always welcome to come by our office for a complimentary consultation, regardless of the type of insurance!

What Are My Benefits?
Every insurance company offers different benefits. Medical, dental, and orthodontic insurance are all considered different benefits. In most cases, orthodontic insurance has a “one-time use” benefit, called a lifetime maximum. Your insurance company may pay up to this amount towards braces.

Should I Purchase a Second Insurance Plan for Braces?
This is a tough question!  There are hundreds of policies with many exclusions. Policies and coverage may change on a daily basis. We recommend that you first contact the HR department at work, or a representative for the insurance company to get a layout of their plans. Please be aware that secondary insurance may sometimes have fine print that they will not pay if there is a primary insurance. It is important when contacting an HR representative or an insurance company representative that this question is specifically addressed so you can rest assured the secondary insurance will provide coverage.

What is a Lifetime Maximum?
Unlike other dental benefits, most orthodontic benefits do not renew each year. Insurance companies call this a lifetime maximum. This means the orthodontic benefit can only be used once per duration of having that insurance.

Does My Insurance Company Pay for Each Appointment?
It is important to remember that orthodontic benefits are typically paid over the course of treatment in monthly, quarterly, or even yearly installments. This is why it is very important to keep your coverage throughout the course of treatment in order to receive the full benefit.

How Do I Check My Eligibility?
Some employers offer orthodontic coverage, but they have rules about who may or may not receive those benefits. Some policies require you to work a minimum number of hours per week, or there may be a waiting period for new employees. Our insurance specialists will verify your orthodontic benefits before your free consultation to let you know if you are eligible for orthodontic benefits!

Work in Progress
If you get a new insurance company while in treatment, or if you transfer to our office from another location to continue treatment, your new insurance company will consider the braces as a “work in progress”. Most insurance companies will prorate your benefit based on what the prior coverage paid and/or the remaining treatment time. Not all plans allow for work in progress. Every insurance company has their own little formula that they use to determine how much they will pay for a work in progress claim. We can help you navigate that tricky slope!

Primary vs. Secondary Insurance
When a patient is enrolled in two active insurances, this is called “dual coverage.” Our office will do our best to help determine how much each policy will pay towards braces. Some insurances have special rules or exclusions on the policy that may make it impossible to collect the maximum amount on both insurances.

The plans determine which insurance is primary and which is secondary; we as providers and you as the patients are not able to determine or choose which is primary. Sometimes they use a “birthday rule.” This means the parent whose birthday comes first in the calendar year may be considered to be your child’s primary coverage. Since each insurance has their own set of rules, it is important to have a knowledgeable insurance specialist to help navigate the systems!

Additional Procedures
If extractions or other dental work is needed throughout orthodontic treatment, your policy may charge your “dental benefits” or your “orthodontic benefits”. These are typically separate benefits and each insurance company has their own rules about which one will apply.

 

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