Dental Coverage

Paying for Orthodontics

Summary

Orthodontics is the field of dentistry that fixes misaligned teeth and jaws using braces and other corrective procedures. Many dental plans cover orthodontics, but the coverage often differs from other dental services. You will most often pay a higher share of the cost for orthodontic care. Coverage is typically limited to children, and there is often a lifetime maximum. Orthodontic services usually go on for many months, or even years. The lifetime maximum is usually separate from the yearly maximum the plan will pay for other dental care.

Plans that cover orthodontics often pay up to 50 percent of the charge. To help you pay the rest, most orthodontists offer payment options like installment plans or financing. They may also offer discounts for paying the full cost up front. Do you have a flexible spending plan through your employer? If so, you may be able to use it to pay for orthodontic costs your plan doesn’t cover.

Like medical plans, dental plans have networks of providers who have agreed with the insurer to be paid set rates for specified services. Different types of dental plans have different rules about going to a provider outside the network. But, you will most often pay more if you do. Ask your dentist to send you to an orthodontist in your plan’s network.

To help manage the cost of orthodontics:

Talk about the cost and your payment options with your orthodontist.
Find out if you can use the funds in your flexible spending plan. If so, make sure you know how much you are going to have to pay, and when. That way, you will know how much money to put away. You can only use these accounts after the services have already been given, so planning is important.

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.

How Much Will My Dental 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 percent) up to a maximum amount.

Diagnostic and preventive care, like cleanings, exams, and x-rays. These services are usually covered in full (100 percent) 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 percent of a maximum amount is common.
Major restorative care, such as crowns, bridges and dentures. Plans usually pay 50 percent of a maximum amount for these services.
Orthodontic services. Plans often cover up to 50 percent 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 copayment 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.

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.

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.

Paying for Orthodontics (Braces): FAQs

Do dental plans cover orthodontics (braces)?

Many dental plans cover orthodontics, but the coverage often differs from other dental services. Coverage for orthodontics is typically limited to children, and there is often a lifetime dollar maximum. Plans that cover orthodontics often pay up to 50 percent of the charges up to a lifetime maximum. In addition, some plans may only cover orthodontics that are “medical necessity” according to the plan’s requirements.

How will my dental plan cover the dental services I receive?

Dental plans usually define four areas or “classes of service.” And each class may be covered differently. These classes include:

Class I: Diagnostic and preventive care, such as cleanings, exams and x-rays. These services are usually covered in full for in-network care (100 percent).
Class II: Basic restorative care, such as fillings, periodontal work and root canals are typically reimbursed at a lower rate — 80 percent is a common level of coverage for basic services among dental plans.
Class III: Major restorative care, such as crowns, bridges and dentures are often covered at a 50 percent level.
Class IV: Orthodontia, such as braces. This class of service usually has a separate lifetime maximum, which applies to the entire course of treatment and is not part of your annual maximum for other dental services. These services are usually covered at a 50 percent level of coverage.

How do I pay for orthodontics?

Your dental plan will pay for orthodontic services up to the lifetime maximum. Usually the plan will make an initial payment at the start of active care (banding) and then pay out the balance over — up to the lifetime maximum — a period of months, many times up to the length of treatment time, or 18 months.

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. Most orthodontists offer payment options like installment plans or other financing. They may also offer discounts for paying the full cost up front. And, if you have a flexible spending plan or health savings account (HSA) through your employer, you may be able to use it to pay for orthodontic costs your plan doesn’t cover.

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 that the plan will cover these services from an out-of-network dentist. If they do, you should also ask if the lifetime maximum is different if the dentist is out of network. Usually the plan will pay in-network and out-of-network dentists in a similar manner: an initial payment followed by monthly payments. But the out-of-network dentist may charge more than an in-network dentist would accept from your plan, so your out-of-pocket costs for visiting an in-network dentist will typically be less, even if the orthodontic lifetime maximum benefit is the same for in-network and non-network providers.