Insurance
- Eligibility
- How Benefits are Calculated
- Flexible Benefit Plans and Executive Management Plans
- What If I Have Multiple Coverage?
- How Can Our Orthodontic Office Help?
As you begin orthodontic treatment, an understanding of how your orthodontic insurance works will be helpful. Orthodontic benefits are separate from dental benefits. Even though you are covered by dental insurance, you may not have orthodontic coverage. A plan booklet is generally available to you from your employer that describes the details of your policy and should outline any orthodontic coverage that might be available to you and your family. We recommend that you familiarize yourself with the details of your coverage to avoid any misunderstandings.
After your new patient examination, we will contact your insurance carrier for you to verbally confirm your orthodontic insurance benefit.
Eligibility
The requirements for eligibility vary by policy. Some policies require a waiting period for new employees, while others may require a specific number of hours to be worked per pay period to remain eligible. Orthodontic coverage in some cases is available only to dependent children under the age of 19. If you are unsure of eligibility requirements, you should refer to the plan booklet or contact the insurance administrator at your place of business. In addition, we would be happy to contact your insurance company to pre-authorize or inquire about your coverage. Pre-authorization does not obligate you to treatment in any way.
How Benefits are Calculated
There is no universal formula for calculating the amount to be paid toward the initial appliance placement fee or subsequent monthly fees. Each policy maintains its own formula. As an example, however, it is common for orthodontic benefits to be paid at 50% of the treatment fee to a lifetime maximum amount. Your policy may have a yearly deductible. Most policies allow us to bill an initial payment of 25% of the total fee with the remaining payments made monthly over the course of treatment.
Flexible Benefit Plans and Executive Management Plans
Flexible Benefit Plans have become a very popular method of projecting "before tax" dollars to be spent during the next plan year. These types of plans commonly allow the insured to allocate a specified number of salary dollars toward certain expenses, usually medical, dental, or childcare expenses. Because these dollars are not subject to payroll taxes, they are a very attractive way of increasing the value of your "insurance dollars." In most cases, there are very specific rules about when orthodontic treatment is initiated to receive the greatest benefit. You must declare the amount to be spent for the year prior to the beginning of the plan year. The plan year for the policy may not be a calendar year. You stand to receive the greatest benefit by planning how orthodontic treatment can fit into the rules of your Flexible Benefit Plan. We are happy to assist you in receiving your greatest benefit and can best do so if you schedule in our office well in advance of the date you must declare your next year's allocation.
What If I Have Multiple Coverage?
If the patient is covered by more than one orthodontic insurance policy, the carriers will determine which plan is considered the primary policy. Often this determination is made by birth dates of the insured parties. The method of determination is not universal, but is individual to each carrier. The secondary insurance carrier will not declare or pay benefits until the primary carrier has made a determination of treatment that will be covered. The secondary carrier usually requires written confirmation from the primary carrier of the benefits to be covered. Recently, some secondary carriers are reducing their coverage by the amount paid by the primary carrier.
How Can Our Orthodontic Office Help?
After providing us with your insurance information, we will bill your insurance carrier directly. We will be your advocate to help you attain maximum benefit from your insurance. We employ a specialist in the language and coding of insurance claims. Please feel free to contact us with any questions or concerns regarding your insurance at 336-6805.