Insurance Coverage - Are You Getting What You Pay For?

When a parent realizes that their child needs braces, they are usually very happy to find out that they have orthodontic coverage that will pay a portion of the costs. Unfortunately, more parents are now finding out that the rules are changing and if insurance paid a portion of orthodontic treatment for a Phase 1, they will not cover any of Phase 2, which is often more expensive for the parent and the insurance company. Depending on the insurance company and the patient's treatment plan, a 1st Phase of orthodontic treatment may only beneift the patient a few hundred dollars, while a Phase 2 payout by the insurance company may cost the insurance company a couple of thousand dollars.

I was recently speaking to a customer service representative at one of the nation's largest insurance company's, trying to get information on a patient's orthodontic coverage, when I was informed that insurance will no longer cover both phases of orthodontic treatment. I was told that if a patient has Phase 1 or braces on the primary teeth, then insurance won't cover a Phase 2 or braces on the permanent teeth later on if needed.

While on the surface, this may not seem like a big deal to a lot of people and the reasoning behind it is being touted as a way for employees to save money on their dental  premiums, most people who have had a 1st Phase of orthodontic treatment, don't realize that they often continue to pay for benefits that they will not be able to benefit from at a later date.  To compound the problem, the majority of patients that need a Phase 1, need a Phase 2 when the permanent teeth come in. Phase 1 is usually required when there is a potentially destructive dental issue at hand. An example would be a cross bite that can damage the teeth when they hit each other each time the child closes their mouth to chew their food. In this case, without a Phase 1 of orthodontic treatment, there is a possibility that the teeth will chip and/or break.

Lesson learned? If your child had a 1st Phase of orthodontic treatment, verify with your insurance comapny that if your child needs additional orthodontic treatment at a later date, he or she will be covered. If you won't be covered for a second phase, you need to make sure you are not paying for orthodontic coverage that you will not benefit from and you may want to shop around for another dental plan that will help you cover the expense at a later date.

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.

When Are Two Phases of Orthodontic Treatment Necessary?

Did you know that the American Association of Orthodontists recommends that a child visits an orthodontist by the age of seven in order to determine if the child has any developmental problems with their jaw and teeth? It is at this time that the doctor determines if it is necessary to begin Phase 1 of orthodontic treatment, in order to prevent bigger problems with the patient's teeth and bite in the future.

Phase 1 orthodontic treatment may or may not include braces. In some cases, a spring aligner, head gear or a palatal expander may be used exclusively, while at other times, it is necessary to get braces to help move the teeth into position so that the permanent teeth can come in more easily.

Phase 1 is almost always followed with a Phase 2, after all of the adult teeth have come in. Often many parents assume that they must wait until a child has all of his or her permanent teeth, only to find out that treatment would have been much easier if started earlier. Early treatment can eliminate the need for more drastic measures, such as surgical exposures to expose permanent teeth that can not erupt due to the position of other teeth blocking its' path. Unfortunately, in some cases, satisfactory results are unattainable once the face and jaws have finished growing. With proper timing, children may not have to endure years of embarrassment.

Below are some of the benefits of early orthodontic treatment.

Early treatment provides the opportunity to:

• Guide the growth of the young jaw bones creating a better environment for those new emerging permanent teeth.
• Guide incoming teeth into optimal positions.
• Regulate the width of the jaws.
• Lower the risk of trauma to prominent front teeth .
• Correct harmful sucking habits.
• Reduce the likelihood of teeth becoming stuck or impacted under the gums .
• Preserve or gain space for arriving permanent teeth .
• Allow easier correction if found early.

Crowded and rotated teeth can break easily and can trap food particles that cause tooth decay and gum disease. Crooked teeth can also cause abnormal wear of tooth surfaces, difficulty speaking, and excess stress on supporting bone and gum tissue. Without treatment many problems become worse. Finally, crooked teeth detract from your smile which is one of the more important facial features. You only have one chance to make that first impression, so make a great one with a great smile!

To find out what Dr. Eder recommends for your smile, please call our office and schedule your Free Consultation today! (561) 737-8776.