One of the first questions we are asked when we see a patient for their free examination and consultation is “Does my dental insurance cover braces?”.
Most of the major insurance companies (Manulife, Sunlife, Great West Life) DO have limited orthodontic coverage under SOME of their plans. Many of their policies, however, do NOT cover any orthodontic treatment at all. The only way to know for sure is for our office to send a treatment plan and estimate to the insurance company. Based on this ‘pre-determination of benefits’, the insurance company will send a response to the insured person. This response will outline what type of reimbursement can be expected. Our staff ‘speaks insurance’ and is available to review the insurance company’s response to make sure there are no hidden surprises in the fine print and to make sure you will receive all the insurance dollars that are available to you.
Here are some general guidelines for orthodontic coverage and answers to the most commonly asked questions:
-The better the plan, the more likely there is some coverage for orthodontic treatment
-Insurance companies will not begin reimbursing anything until they have received and approved the predetermination (treatment plan and estimate) from our office
-Orthodontic insurance is paid as a reimbursement. When we process your payment, we will submit the receipt to your insurance company (electronically, if they are set up to receive those transmissions) and they will reimburse you the amount they cover
-Most policies that have orthodontic coverage reimburse a percentage (such as 50%) and most have a lifetime maximum payable for orthodontic treatment (such as $2000 per person, per lifetime)
-Insurance companies will almost never ‘pay in full’ for orthodontic treatment. They usually want to see a breakdown of a payment plan that is divided into ‘diagnostic’, ‘initial payment’ and ‘monthly payments’. Our payment plans are designed to be insurance friendly
-If there is coverage under two plans (such as both parents have orthodontic insurance coverage), the parent who’s birthday comes first in the year is considered the primary insurance. The receipt is submitted to that insurance first. When the primary insurance has made their reimbursement, a copy of the cheque stub is attached to a claim form that is then submitted to the other parent’s (secondary) insurance. The second insurance will then reimburse what they cover (up to a total of 100%)
-Most insurance policies that cover orthodontic treatment have limitations and restrictions such as age limitations, coverage for full time students only or a ‘wait period’ (meaning that you must pay premiums for a period of time before you are allowed to claim orthodontic treatment).
-Insurance companies will only reimburse for orthodontic treatment as long as the insurance is still in effect. If you quit your job and your insurance ends, your insurance company will stop your reimbursements
Dr. Shojaei’s team is very well versed in all aspects of orthodontic insurance. We are happy to support you in making sure you receive every insurance dollar available to you. We will gladly review your insurance questions at your free examination and evaluation and make sure that there are no surprises hidden in the fine print. We’re happy to help. That’s what we’re here for!