Understanding Your Insurance

Frequently Asked Questions:

Eligibility - The requirements for eligibility for orthodontic coverage 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 in order to maintain eligibility. In some cases, orthodontic coverage is only available to dependent children under a certain age. If you are unsure of eligibility requirements, you should refer to the plan booklet or app, or contact the insurance administrator at your place of employment.

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 for treatment as each policy maintains its own formula. However, some of the most common plans pay out their orthodontic benefits at 50% of the treatment fee to a lifetime maximum dollar amount per eligible insured party. Your policy may also have a yearly deductible that you must reach before benefits begin.

Multiple Coverages – If the patient is covered by more than one orthodontic insurance policy, the carriers will determine which plan is considered the primary policy for that patient. Often, this determination is made by the birthdates of the plan holders. With children, for example, the parents’ birth month often determines which policy is primary and which is secondary. For adults, the patient is most often the primary policy and the spouse is the secondary policy.

Again, this method is not a universal formula, as that will be specific to each policy carrier. The secondary insurance carrier will not declare or pay benefits until the primary carrier has made a determination of the amount of treatment that will be covered. The secondary carrier usually requires written confirmation from the primary carrier of the amount of benefits to be covered within the primary plan.

At the start of your treatment, we will have you sign all of the insurance claim forms that will be required to bill your insurance carriers directly. If your coverage changes or ends for any reason, you will be responsible for any outstanding balance on your account.