Orthodontic Insurance Coverage


Orthodontic Dental Insurance: What does it actually mean?

Today, many dental plans include orthodontic benefits that are designed to cover a portion of your orthodontic treatments. Orthodontic insurance makes getting braces affordable, especially for those people who may not pursue orthodontic treatment for financial reasons.

The coverage and benefits depend on each individual orthodontic insurance plan. Typically, most insurance companies that offer orthodontic coverage will recognize 20% for the down payment to begin treatment and will then cover 50% of the monthly charges until the lifetime maximum coverage is reached.


**This example is for illustration purposes only and may not reflect your specific coverage.

If your treatment cost is $5,000 over 24 months and your orthodontic insurance lifetime max was $2,000 with 20% initial and 50% per month, the insurance benefit would be:

›››› Maximum down payment recognized would be $1,000 (or 20% of the total cost)
       **This means if you put more than $1,000 down the insurance company will still only recognize $1,000 initially.
›››› Maximum down payment coverage would then be $500.00 (or 50% of the above $1,000)
›››› Maximum monthly payment coverage would be 50% (until the lifetime max of $2,000 is reached)

**So if you put $1,000 down, you would receive $500 initially and $83.33 (or 50% of $166.66) per month from your insurance company for about 18 months until the lifetime maximum of $2,000 is reached. Payments are usually quarterly.

**This means that even if you paid for the entire treatment upfront, your insurance company will still only reimburse you monthly (as shown above) until your lifetime maximum is reached. So paying all the expenses upfront will not usually get your insurance benefits paid any faster.

What does out-of-network mean with your insurance coverage?

Most orthodontic offices do not participate with dental insurance companies but that does not mean your treatment won’t be covered. Orthodontic insurance works differently than any other insurance coverage, and typically any insurance plan that has an out-of-network orthodontic benefit can be utilized. Typically, it pays back about 10% per month slower. So it may take two to three months longer for out-of-network insurance policies to receive the full lifetime benefit.

How can you maximize your insurance coverage?

Sometimes both parents have dental insurance available. When this happens most insurance companies follow the universal rule of billing initially the parent’s whose birthday comes first in the calendar year. After the lifetime maximum is reached, the other parent’s insurance would then be billed. Furthermore, if during treatment your insurance changes, that can actually be a benefit. This is because if your new insurance coverage has orthodontic coverage, you can bill it until the new lifetime coverage is met. So there is a lot to understand with insurance coverage and at the initial visit to our office we will look into your specific coverage.

How will your insurance be billed?

We try to make the insurance process as easy for you as possible. Therefore, we use a computerized insurance process that will automatically bill your insurance provider every month. Insurance reimbursement checks are sent directly to the insurance cardholder. Please understand that we will assist you with the insurance filing but cannot guarantee that treatment will be covered by your insurance carrier, and ultimately you are responsible for all charges incurred.