Demystifying Dental Insurance and Understanding Coverage for Braces

Discover the ins and outs of dental insurance coverage, including braces, and learn how to find the right plan while saving money on your dental expenses.

At any given time, approximately 4 million individuals in the United States are wearing braces, and it's important to note that braces are not exclusively for children [1]. Surprisingly, one out of every three orthodontic patients is over the age of 18 [2].

While braces are fairly common, they can be quite costly if not covered by dental insurance. On average, the expense of traditional braces without insurance falls within the range of $5,000 to $6,000. If you have dental insurance or are contemplating enrolling in a plan, you may be curious about the specific coverage provided for orthodontic treatment. To address your queries, here's a comprehensive overview of dental insurance and its coverage for braces.

What Does Dental Insurance Entail?

Dental insurance differs from typical medical insurance coverage as it is generally a separate, optional plan that can be obtained independently. Its functioning may not always align precisely with medical coverage.

Dental insurance is a policy designed to assist in covering the expenses incurred for services provided at a dental office. Similar to medical insurance, it involves paying a monthly premium. However, it is important to note that dental insurance does not operate in the same manner as traditional insurance. According to Alex Karrenbrock, a sales associate at Apollo Insurance Group in Lees Summit, Missouri, dental insurance is more akin to a discount plan with limited benefits. When you visit an in-network dentist, they are contractually obligated to charge you the discounted insurance fee rather than their regular office fee, which is typically 20% to 40% higher. The extent of coverage provided by your dental insurance depends on the specifics of your plan and the benefits it offers.

While dental insurance may not cover the entirety of your dental expenses, it can be advantageous in terms of cost savings for preventive care and necessary dental procedures. Dental treatments can become quite costly, and insurance often helps alleviate the financial burden associated with them.

Various Types of Dental Insurance

According to the American Dental Association (ADA), there are eight primary types of dental insurance, and understanding their distinctions is crucial if you are seeking coverage.

  1. Preferred Provider Organizations (PPO) plans resemble health insurance in that they establish a network of dentists who are contracted by the insurance company to provide dental services at predetermined fees. These plans generally offer comprehensive coverage for costly procedures such as implants, braces, and surgery. PPOs also tend to have reputable dentists within their networks, and some plans even allow out-of-network benefits. However, most PPO plans have a benefit limit (typically $1,000 to $2,000), after which the individual is responsible for the entire amount, albeit at a discounted insurance rate, resulting in potential savings of up to 40%.
  2. Dental Health Maintenance Organizations (DHMO) plans allocate a fixed amount of money to dentists each month for each patient assigned to them. Dentists are then required to provide certain services at reduced or no cost to these patients. DHMO plans often offer unlimited benefits, but there is usually a copay for all procedures. Additionally, these plans may have more restrictions and lack coverage for higher-end procedures. Participation in DHMOs can be limited as some dentists opt not to join due to relatively low reimbursements, which may affect access to more experienced providers.
  3. Indemnity plans closely resemble traditional health insurance structures. The insurance company pays claims based on the performed procedures and typically allows patients to choose their own dentists. The dentist is paid a percentage of the bill on behalf of the patient according to the plan's guidelines.
  4. Direct Reimbursement (DR) plans require individuals to pay the dental bill upfront and then file a claim with the insurance company to receive a reimbursement check at a later time.
  5. Point of Service (POS) plans enable patients with managed care dental plans to receive treatment from out-of-network providers. While patients may receive partial reimbursement, the benefits are significantly reduced compared to in-network providers.
  6. Discount or referral plans are technically not insurance plans. They function as alternative options that provide discounts on dental services, similar to coupons at a grocery store. However, individuals are still responsible for paying the discounted bill in full.
  7. Exclusive Provider Organizations (EPO) plans only permit patients to seek treatment from participating dentists to be eligible for reimbursement. Consequently, these plans restrict dentist choices and limit access to care.
  8. Table or Schedule of Allowances plans require users to pay a predetermined amount for each procedure, with patients responsible for covering the difference between the fee and the payment provided by the insurance carrier.

Coverage and Limitations of Dental Insurance

The extent of coverage provided by dental insurance depends on the specific type of plan you have, as there are numerous variations available. Dr. Pinto emphasizes that dental plans can range from minimal coverage, focusing primarily on preventive care, to comprehensive plans with unlimited benefits that cover a wide range of treatments. To gain a clear understanding of your plan's benefits, it is advisable to consult your insurance carrier or, if applicable, your employer's human resources department.

However, Karrenbrock highlights that dental insurance plans generally cover the following:

  1. Preventive services: This category typically includes regular cleanings, examinations, and bitewing X-rays. In some cases, teeth whitening may also be included.
  2. Basic services: Basic dental services encompass procedures such as cavity fillings and simple tooth extractions.
  3. Major services: Major dental services often covered by insurance include crowns, bridges, root canals, wisdom tooth extractions, periodontic deep cleanings, oral surgery, dentures, and partial dentures.
  4. Orthodontia: Coverage for orthodontic treatment, including braces and retainers, falls under this category. However, it is worth noting that most insurance companies do not cover braces for adults over the age of 18.

Nevertheless, dental policies typically have limitations and exclusions, so it is essential to review these aspects before purchasing a plan. For instance, there is commonly a missing tooth clause in dental policies, meaning that if a tooth is already missing prior to obtaining the plan, the insurance company will not cover the cost of replacing that tooth. Dental insurance often does not cover procedures like implants or adult braces. Additionally, waiting periods may apply, wherein certain procedures are not covered until a specified period has passed. Elective or cosmetic dental work is generally not covered by dental insurance.

It is crucial to review the specifics of your dental insurance plan to fully understand its coverage and any limitations or exclusions that may apply.

Understanding Dental Insurance and Coverage for Braces

Dental insurance plans often provide coverage for braces, but it's essential to be aware of certain caveats and important details. Karrenbrock explains that you need to select a plan that covers braces, but even then, they must be deemed medically necessary.

Coverage Restrictions Orthodontia coverage may come with additional restrictions. Dr. Pinto points out that a common restriction is that braces are typically covered only once in a lifetime. Therefore, if you had braces in the past and require them again due to not wearing your retainer, the cost won't be covered. This restriction applies even if you obtain a new insurance plan through a different job but from the same insurance company. Age is another significant limitation. While most dental insurance plans require the individual to be under 18 years old, some plans may not cover braces for anyone over 16 years old.

Medicare Coverage In general, Medicare does not typically cover dental expenses. Karrenbrock explains that individuals with Medicare coverage often opt for a separate dental insurance plan to address their dental needs.

Using HSAs and FSAs for Payment Funds in health savings accounts (HSAs) and flexible spending accounts (FSAs) can be utilized to pay for dental bills. However, Karrenbrock notes that using these funds does not impact the price. Instead, it provides the benefit of associated tax advantages.

Alternatives to Braces Alternative treatments to braces, such as Invisalign, retainers, headgear, and veneers, may be available. Some dental insurance plans cover these alternatives, although the out-of-pocket costs may be higher compared to other services. Dr. Pinto explains that treatments like Invisalign are still covered but are typically considered upgraded services. If you choose Invisalign, it is understood that you are opting for a premium service beyond the standard braces covered by your insurance. Therefore, you will be responsible for paying the difference between what your doctor charges for Invisalign and what your insurance provider covers.

Locating a Dental Insurance Plan that Includes Braces Coverage

When seeking a dental insurance plan that covers braces, Karrenbrock suggests enlisting the assistance of a broker who can aid in finding the most suitable plan. "In general, you should search for a plan that includes coverage for 'orthodontia' and carefully review any limitations or exclusions associated with the plan," he advises.

Ways to Economize on Dental Insurance

Expenses Dental insurance costs can accumulate rapidly, but it's important to remember that paying for coverage on a monthly basis can potentially save you money in the long term, especially if you require major procedures or braces. Here are a few tips to consider when seeking ways to save:

  1. Enroll in an employer-provided plan: Both Karrenbrock and Dr. Pinto agree that obtaining dental insurance through your employer is the best approach. Dr. Pinto explains, "It tends to be more affordable, offers better benefits, and typically doesn't involve waiting periods."
  2. Steer clear of individual dental insurance: Dr. Pinto advises against individual dental insurance due to its higher cost, waiting periods, and additional restrictions. She mentions, "Most individual plans provide limited coverage, usually restricted to cleanings and exams, during the initial six months to a year because of waiting periods."
  3. Seek practices with membership plans: Some dental practices offer membership plans that feature lower annual fees and include specific treatments. Dr. Pinto highlights the growing popularity of these plans, stating, "While such membership plans were uncommon in the past, they have now become more widespread and can be a great option." However, it's important to note that these plans generally limit you to receiving care at the particular dental practice offering the membership.

By considering these strategies, you can work towards reducing your dental insurance expenses while still maintaining essential coverage.