Keys to Orthodontic Insurance
When you first visit Bailey Orthodontics please bring your current insurance card with you. Our staff works hard to verify your benefits and provide you with information regarding your dental plan. With that being said, coverage is a contractual agreement between a patient and the patient’s insurance, not Bailey Orthodontics. Many policies have a lifetime orthodontic maximum that is separate from regular dental insurance. Our office is happy to help identify the insurance benefit, however any information obtained from your insurance is not a guarantee of benefits.
As a courtesy to our patients we will file claims for you. Remember that policies vary, have different maximums, pay benefits differently and may have different clauses/waiting periods. It is customary for companies to pay out orthodontic benefits on a monthly or quarterly basis over the course of the patients treatment; rarely do they pay one lump sum. If for any reason the company pays less than the estimated benefit, the financially responsible party is accountable for all charges. Please notify Bailey Orthodontics of any changes in your coverage or carrier as soon as possible so we may identify how it may affect your contract.
Common Terms Used in Orthodontic Insurance
Lifetime Maximum: This is the total dollar amount that your insurance company will pay toward treatment in a patients lifetime.
Percentage Payout: Typically, these companies will only pay a percentage of the total fee (often 50%) up to the lifetime maximum.
Waiting Period: Sometimes there is a waiting period from the time you obtain dental insurance until the time when you can begin utilizing your orthodontic benefits.
Age Limits: There may be age limits on orthodontic benefits, sometimes restricting coverage to dependent children only.
Dual-Coverage Clause: If you and your spouse both have dental coverage, it is important to know if the secondary coverage will allow for dual coverage. That means you may not be able to take advantage of both benefits.
Maintaining Coverage: As a policy holder, you must maintain your dental coverage throughout the entire orthodontic treatment plan in order to receive benefits. If you change plans or lose coverage, you will be responsible for the balance no longer paid out by the coverage plan.
Frequently Asked Questions
This covers some of the most frequently asked questions about orthodontic benefits through your dental coverage. Please call our office for any further questions.
What coverage plans does your office accept?
Here at Bailey Orthodontics we strive to be a participating provider in all major coverage plans to make orthodontic treatment accessible and affordable for our patients. Our office accepts most plans. Please give us a call and we would be happy to verify that we will be able to accept your benefits.
You are not listed as an in-network provider on my coverage plan. What should I do?
If Bailey Orthodontics is not listed as an “in-network” provider on your insurance plan that doesn’t necessarily mean that you won’t receive payment from your insurance for your treatment here. Often there is no difference between in and out-of-network contributions with specialized dental treatment like orthodontics. We are happy to check your benefits for you.
How does dental insurance work toward orthodontics?
Orthodontic coverage generally differs from general dental coverage in that each insured individual usually has a lifetime maximum benefit for orthodontic services. This benefit is paid as a percentage of the orthodontic fee until the benefit maximum has been reached. Charges for lost or broken appliances may not be covered.
How does the insurance company pay?
Most companies make an initial “down payment” for the initial claim submitted for your treatment. Followed by either monthly or quarterly payments over the course of treatment. Rarely does a company pay in one lump sum. It is important that you maintain coverage throughout the course of your treatment to ensure that you receive your full benefit.
What happens if I get new insurance during treatment?
If you get new insurance during treatment, please let us know as soon as possible so we can work on getting your benefits verified and filed for you. In most cases, you will not receive the “down payment”, but you will receive the monthly payments from the effective date of your new insurance through the remainder of your treatment.
If any changes to your insurance occur during your orthodontic treatment (such as switching companies or joining another employer’s plan), please be sure to let us know. Changes to your plan may affect your payment and amount personally owed to the practice. If, during the course of treatment, your benefits change, the financially responsible party is accountable for all charges.
What happens if I change companies or lose my job?
If you lose your job or change companies, the orthodontic benefits will be “terminated” on that day. Any balance that the company did not pay will become your responsibility. In either case, we will work with you under your particular situation to help you get your balance paid in full. If your new employer offers orthodontic coverage we will file for benefits as soon as you become eligible.
What happens if my employer changes insurance carriers?
Please let us know as soon as possible of any changes to your insurance plan. Typically, this has no effect to your insurance benefits, however, the new carrier’s policy may be written differently and there may be a higher or lower lifetime maximum for orthodontics. There may also be an age limit difference. The best thing to do is check with your human resources representative as soon as you know the change is going to occur, to familiarize yourself with the benefit changes, if any. Once you are covered by the new plan, call our financial coordinator to update your benefits.
If my employer changes insurance carriers, will I now get to claim the new insurance plan’s full lifetime maximum?
No, there is typically a grandfather clause that simply picks up where the last policy left off and continues until the lifetime maximum has been met.
My child is in orthodontic treatment and I just changed employers. Will I get to collect the full lifetime maximum at my new employer?
If you change your employer during treatment, the current insurance will stop making payments when you terminate your employment/benefits. The new carrier, provided there is no waiting period, work in progress clause and they have orthodontic benefits available within the age limits (if applicable) will most likely pro-rate benefits and pick up where the previous plan left off. Unless the new orthodontic lifetime maximum is higher than the first, it is unlikely that you will collect any more benefits than originally estimated.
What is a “work in progress” clause?
A work in progress clause states that, if treatment has already begun, the patient is not eligible for benefits. This is something to watch for if you change jobs. You can ask your employer’s human resources manager, or you may find the information in your employee handbook.
What is a non-duplication of benefits clause?
Some insurance plans have this clause in their policy to indicate that the secondary plan will not pay any benefits if the primary plan paid the same or more than the secondary would have paid if it was a stand-alone plan.
What happens if I leave my employer before the insurance lifetime maximum is reached and I do not have a new plan?
If you leave your employer before the insurance lifetime maximum is reached, no further collections can be made against this insurance plan as you are no longer a member. You will be responsible for the remaining balance that was expected from insurance.
How does this office assist you with insurance?
For your convenience, we will gladly assist you in submitting both predetermination and insurance claims that pertain to charges for services provided in our office. However, please be aware that our primary financial relationship is with our patients and their families, and not with their respective insurance companies. Our professional services rendered are charged to the patient, the family and/or the insurance company. All fees incurred by the insurance company that are unpaid due to any changes, cancellation, or termination of the policy become the responsibility of the patient. Please contact our office to notify us of any changes to your insurance policy and to provide the appropriate updated information.