Those of us who wore braces when we were younger can thank our orthodontists for the straight teeth we have now. Orthodontics is the field of dentistry that deals with fixing misaligned teeth and jaws with braces and other corrective procedures.
Many dental plans cover orthodontics, but the coverage often differs from other dental services. You will usually pay a higher share of the cost, coverage is generally limited to children and there is often a lifetime maximum. Understanding the details of your plan and your payment options now can help you get ready for the time when your children may need orthodontic care.
When is it Time for the Orthodontist?
Orthodontic services are most common for children, although many adults now seek them, too. Generally, your family dentist will tell you if he or she thinks your child may need orthodontic treatment. Your dentist will refer you to an orthodontist - a dental specialist who has trained an additional two to four years beyond dental school. The orthodontist will evaluate your child and let you know if braces or other corrective treatment is necessary. Orthodontic services usually continue for many months or even years, and the cost reflects that.
How Do I Pay?
Even if your dental plan covers orthodontics, you will most likely still have out-of-pocket costs. Because orthodontic services continue for a long period of time, most orthodontists offer a number of ways to pay. These may include:
· Installment payments, spread out over the course of the treatment. With this option, you may have to pay a higher “down payment” when you begin treatment. Some orthodontists may also charge interest if you miss a payment.
· Payment coupons, spread out over a defined period of time. With this option, you might make a payment every month, like you would with a loan.
· Discounted pricing, if you pay the total cost of treatment up front.
· Financing treatment costs over time. With this option, you may pay a lower amount each month, but keep paying it even after the treatment has ended.
If you have a flexible spending account (FSA) or health savings account (HSA) through your employer, you may be able to use it to pay for orthodontic costs your dental plan doesn’t cover. But remember, you can only use money from your FSA or HSA after the service has been provided. If you are planning to use your FSA, make sure you keep track of how much money you will need to put away, and decide whether you will pay in a lump sum or in installments over time. Also, make sure to check what documents you will need to provide to use your FSA or HSA. Sometimes the requirements might be different depending on how you are paying for the care.
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How Much Will MyDental Plan Cover?
Dental plans usually cover four major “classes of service.” Each class is paid differently. These include:
· Diagnostic and preventive care, like cleanings, exams, and x-rays. These services are usually covered in full (100%) up to a maximum amount.
· Basic restorative care, such as fillings, periodontal work and root canals. These services are usually paid at a lower rate; 80% of a maximum amount is common.
· Major restorative care, such as crowns, bridges and dentures. Plans usually pay 50% of a maximum amount for these services.
· Orthodontic services. Plans often cover up to 50% of the charge for the services, up to a lifetime dollar maximum. This maximum is the total your plan will pay for the entire course of treatment. It is usually separate from your dental maximum.
You should also keep in mind that:
· If you are covered by a Dental Health Maintenance Organization (DHMO), you will usually have a fixed co-payment for different types of orthodontic treatment.
· There is usually no deductible for orthodontic services.
· Adult orthodontic care is usually not covered. Plans that cover orthodontic services may limit coverage to members or dependents under the age of 19.
Of course, not all plans cover orthodontic services, and your dental plan’s coverage may be different. It is a good idea to check your dental plan booklet or contact your insurer or plan administrator so that you understand how your plan works, what is covered, and what you can expect to pay out-of-pocket.
What if I Go Out-of-Network?
You may decide to take your child to an orthodontist outside your plan’s network. If you do, make sure to find out how much you may have to pay. Different types of dental plans cover orthodontic care differently. For example, a Dental Health Maintenance Organization (DHMO) usually does not cover any out-of-network care, which means that you will have to pay the full cost. Or, if you have a fee-for-service plan that includes out-of-network care, the lifetime maximum may be lower and you will have pay for any treatments over that limit. A fee-for-service plan might also pay less for out-of-network services than in-network services.
In most cases, there is no major difference between the lifetime maximums for in- and out-of-network services for orthodontics.
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Your Action Plan: Plan Ahead For Your Family’s Care
· If you have a dental plan, read through your plan documents, ask your employer, or call your plan to make sure you know:
· The type of plan (like a DHMO or DPPO);
· Which orthodontic services are covered;
· If and how your plan pays for out-of-network orthodontic services;
· The lifetime maximum amount for orthodontic services (remember, you will have to pay the full cost above that limit);and
· Whether there is an age limit.
· Ask your dentist to refer you to an orthodontist who participates in your plan’s network.
· Discuss the cost and your payment options (such as paying a discounted price for the entire service up front) with your orthodontist.
· Find out if you can use the funds in your flexible spending account or health savings account. If so, make sure you understand how much you are going to have to pay, and when, so you know how much money to put away. Remember that you can only use these accounts after the services have already been provided!
· Learn more about types of dental plans and how they cover your care by referring to our section on Dental Plans: What You Need to Know.
And remember, don’t be afraid to ask your dentist, orthodontist, employer and insurer all the questions you need to know. Understanding your coverage and costs up front now will help you better plan for your family’s future and will give you another reason to smile.
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