Confused about insurance for your orthodontist? You’re not alone. Many insurance companies, such as Delta, have a list of participating providers. If you go to a provider listed in your network you can usually save on your out of pocket costs. Some insurance companies offer PPO (preferred provider organization), a lower level participating provider which is not PPO, and non-PPO benefit levels. Each employer chooses their benefit level with the insurance company. The in-network providers have a separate agreement with each insurance company on the maximum they are allowed to charge for each service. Many of our patients save $300+ more than a patient who is not in a participating insurance.
Not all plans pay a different fee for non-PPO providers. Many insurance companies will pay the same benefit regardless of the provider status.
The Modern Orthodontist participates in Aetna, Delta Dental Premier, Delta Dental PPO, Delta Dental Preferred, United Concordia, Cigna radius, Regence, and Guardian networks.
We have an in office Insurance Coordinator, Levon, who will help navigate your questions regarding your insurance and will directly work with the insurance company to obtain your benefit for you.
Now on to the part of orthodontic insurance that differs from almost any other insurance benefit.
-Orthodontic treatment is nearly always a lifetime benefit and does not renew yearly. It is usually separate from the dental benefit but may include some oral surgery procedures.
-The orthodontic insurance benefit is commonly a set dollar amount with a percentage. The insurance will pay for the % of treatment up to the lifetime maximum dollar amount whichever is less. For example if your benefit is $1500 at 50% and your treatment fee is $400 it will pay 50% or $200. But if your treatment is $3000 or more, no matter how high the fee, the maximum you will receive is $1500.
-Nearly all insurance companies will make an initial payment when the appliances are placed then make payments over the length of treatment. They do this because the adjustment visits are not performed all at once. This means that if you lose or cancel your insurance before treatment is finished you may lose a portion of your benefit. Always check with your provider before canceling your insurance.
-Also some orthodontic benefits have a longer waiting period. So although you may have met the wait period for general dental benefits you may have to wait 6-12months longer before your orthodontic insurance benefit will begin making payments.
-If you have two orthodontic insurances, there is a coordination of benefits that has to be checked to see how the benefits will work together. Usually the birthday rule applies meaning whoever’s birthday is first in the year not which is older. If you are lucky they will coordinate and you will get the full benefit from both insurance companies.