Tuesday, February 1, 2011

Insurance and Braces - Are You Covered?

As anyone with braces can tell you, orthodontic treatment can be very expensive, but dental insurance can help. The trick to getting the most out of your insurance begins with understanding how orthodontic insurance works.

To begin, there are usually limitations on how much orthodontic coverage a person is eligible for. Typically, coverage is limited to 24 months of treatment with an HMO. HMO's also have limitations on which doctor you can see, as they will not pay for treatment if you do not go to one of their participating providers. Fortunately, Dr. Eder participates with most of the major companies and is experienced in jumping through their hoops, to get the most benefit for the patient. This often includes sending in a pre-authorization request before the patient begins treatment.

PPO's on the other hand, usually have Lifetime Maximum payouts. What this means, is that they will only pay a limited amount towards braces, throughout the patient's lifetime. The most common lifetime maximums offered range from $1000 to $1500, but there are plans out there that will pay as little as $500 to as much as $3000. With a PPO plan, you do not have to see an in-network dentist, but you probably won't receive the discounted rates that participating providers usually offer, and once you have used your benefit maximum, you are responsible for all  outstanding charges.

Both the PPO and HMO plans have fee schedules that participating providers must follow when treating patients covered by their respective plans. In most cases, there are some nice discounts, but depending on the plan, they may limit how often a certain procedure may be covered.

Another nice thing about PPO's that differs from an HMO, is that a PPO will usually coordinate benefits with a secondary insurance benefit. Unfortunately, most HMO's will rarely coordinate benefits with another insurance company, unless they are the primary insurance and the PPO is the secondary insurance.

So how do you know which insurance is the primary and which is the secondary insurance when you are covered by 2 insurance policies? With children, the parent whose birth date comes 1st in the year is the primary and the other subscriber whose birthday is later in the year is the secondary. Please note that this does not include the birth year, only the month and day. Which means that if mom's birth date is 6/5/59 and dad's birth date is 7/5/49, mom is the primary and dad is the secondary because mom has her birthday first in the year. There are also exceptions to be made when people share a birthday or when a court orders a certain parent be responsible for primary coverage. When referring to adult coverage, if you have coverage through your employer, you are the primary and your spouse's insurance is your secondary insurance.

To complicate matters even further, insurance companies may  also include a non-duplication clause, which will limit what the secondary insurance pays. In most cases, it means that the secondary insurance company will not pay more than the primary insurance company will pay. So if your primary insurance coverage is for 50% of a procedure up to $1000 maximum and your secondary insurance company benefits are the same 50% up to a maximum of $1000, then the second insurance company will not pay anything towards the procedure. However if the secondary insurance coverage is 80% up to a maximum of $1000, then you should get the benefit of the extra 30% coverage and the secondary company should pay an additional $300.

There are many other situations and clauses that may arise when dealing with dental insurance and orthodontics in particular. One of the main concerns that many people have, has to do with is how and when the insurance company pays for orthodontic treatment. In 99% of the cases, the insurance company will pay for their share of the orthodontic treatment throughout the period that the patient has braces. So if the patient is scheduled to have braces for 24 months, the insurance company will make payments to the doctor, spread out throughout the 24 month period. Unfortunately, this means if you cancel your insurance or lose coverage before the braces are scheduled to come off, the primary subscriber (or patient) is now responsible for paying the doctor whatever amount the insurance company failed to pay.

If you are interested in finding out about your insurance benefits, it is often best to speak to your Human Resource office at your place of business when possible. If it is not possible, I recommend calling the customer service number on the back of your insurance card and asking them to explain your benefits. However, please remember that these customer service representatives are human and can make mistakes, and they will remind you that all benefits quoted over the phone are not a guarantee of coverage. With that said, at Dr. Eder's orthodontic office, we pride ourselves in going that extra mile to help you understand your coverage. To set up an appointment for a Free Consultation, and to have your insurance questions answered please call (561) 737-8776.

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