How to Get Braces Covered by Medical Insurance

Posted on May 31, 2024

braces medical insurance

Getting braces can be a life-changing experience, but it often comes with a hefty price tag. For many, the cost of orthodontic treatment can be a significant barrier to achieving a straighter, healthier smile.

At Smilebliss, we understand the transformative power of a beautiful, healthy smile – that’s why we’ve priced our braces up to 60% less than other local orthodontists. At just $2,998 total, we’re making braces accessible.

On top of our low prices, did you know that it’s possible to get braces covered by medical insurance? 

Our mission is to provide an exceptional smile experience that’s blissful from start to finish— without causing a frown when you check your wallet. A significant part of making orthodontic care affordable involves navigating the often-complex field of insurance for braces.

Understanding the intricacies of insurance for braces and dental insurance for braces can significantly lower your out-of-pocket expenses. This blog aims to simplify the process of getting braces covered by medical insurance, allowing you or your loved ones to begin the journey to a perfect smile with financial security.

Understanding Braces Insurance Coverage

If you need braces and want to figure out how to afford them, you should start by understanding your insurance plan in detail. Coverage for braces, especially for adults, can be very different from one plan or provider to another.

Some dental insurance plans may not cover braces fully, they might place restrictions on age, require a waiting period, or exclude coverage if a condition existed before the policy started.

Moreover, some plans will only cover braces if they’re needed to fix a problem with how your teeth work, not just how they look.

Steps to Make Sure Your Braces Are Covered by Insurance

To make sure your braces are covered, you’ll need to take some initiative.

Here are some steps to help increase your chances of coverage:

  1. Check Your Policy Details

    client discussing with an insurance agent a dental insurance. All screen graphics are made up.Take a close look at your insurance policy paperwork, especially the section about orthodontic coverage.

    Pay attention to details like age limits, whether or not you need to use certain doctors, how much you need to pay before your insurance starts to help (your deductible), what portion you need to pay for services (co-payment), and the maximum limit on how much the insurance company will pay.

  2. Talk to Your Insurance Company

    If there’s anything you’re not sure about in your policy, don’t hesitate to call your insurance company. They’ll be able to give you the most reliable and up-to-date information about what’s covered when it comes to braces.

  3. Confirm Medical Reasons

    Your insurance may require proof that braces are necessary for health reasons, not just to improve your appearance. You may need to provide documentation, like a detailed explanation and images from your dentist, to show why you need braces.

  4. Choose Covered Providers

    Using doctors who are in your insurance plan’s network can bring significant benefits and may help reduce your costs. Confirm with your insurance company that the dentist or orthodontist you have chosen is in their network of providers.

  5. Get a Pre-Treatment Estimate

    Ask your healthcare provider for a pre-treatment estimate (also called a predetermination of benefits). This detailed estimate, showing the cost of treatment and how much is covered, can be provided to your insurance company to get an idea of how much they will pay.

  6. Get Pre-authorization if Needed

    Some insurance plans require pre-authorization before you can start orthodontic treatment. Your dentist or orthodontist can help you with this by sending treatment plans and other necessary paperwork to your insurance company for approval.

  7. Understand Your Out-of-Pocket Costs

    Keep in mind that you may have additional costs, even with insurance. Understand things such as your deductible, co-payments, and co-insurance, and how much of the cost of braces is covered. Take note of any limits or grace periods.

  8. Keep All Your Records

    Keep detailed records of all your contacts with your insurance company, including notes, dates, and names of the people you talk to. Also preserve all paperwork, such as claims, pre-authorization forms, and payment receipts.

Getting to Know Insurance Coverage for Kids vs. Adults

Insurance for orthodontic treatment tends to be different for kids versus adults. A lot of insurance policies provide better coverage for kids under 18, considering braces as necessary for proper dental growth. 

For adults, braces might be seen as more of a beauty treatment, which can mean less coverage. It’s important to look into this aspect of your policy to know what to expect.

How to Get the Most from Your Insurance Benefits

  1. Yearly Maximums: Pay attention to the highest amount your plan will pay for dental care in a year. In some cases, you could get more benefits if you spread out your treatment over two years.
  2. Choose a Provider in Your Network: Picking an orthodontic provider that’s part of your insurance plan’s network can save you money. Smilebliss is an example of a provider that works with insurance networks, offering services at rates agreed upon with the insurance company, which can lead to lower out-of-pocket costs for you.
  3. Convenient Billing and Payment Options: Smilebliss offers flexible ways to pay and may even be able to bill your insurance company directly, which can make the payment process a lot easier. Monthly payments at Smilebliss are just $123/month.

Looking into Other Coverage Options

If your current health insurance doesn’t cover braces or only covers a small portion, you might want to explore other options.

This could mean choosing a different plan from your current provider that has more coverage for orthodontics or looking into standalone dental insurance that may cover or help pay for braces.

Medical vs Dental Coverage

Braces are typically covered by dental insurance, but there can be exceptions. In some cases, medical insurance might cover braces if they are deemed medically necessary. This means braces are needed to correct a problem that affects your overall health, not just the appearance of your teeth.

Here’s a breakdown of what medical coverage for braces might involve:

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  • Meeting Medical Necessity Requirements: Your insurance company will likely have specific criteria for what qualifies as “medically necessary” for braces. This might involve documented jaw problems, breathing difficulties, or severe speech impediments caused by misaligned teeth.
  • Getting a Referral and Documentation: You’ll likely need a referral from your dentist or orthodontist stating the medical need for braces. They might also need to provide additional documentation to support the claim.
  • Pre-approval and Working with Your Provider: Many medical insurance plans require pre-approval for treatment before coverage kicks in. It’s important to work closely with your healthcare provider to navigate the process, including submitting documentation and managing any payments.

Remember: Insurance specifics vary greatly. Contact your insurance company directly to understand their policies and requirements for braces under medical coverage.

Alternative Options for Managing Costs:

  • Health Savings Accounts (HSAs) or Flexible Spending Accounts (FSAs): These accounts let you use pre-tax dollars for qualified medical expenses, potentially lowering your overall braces cost. However, eligibility and contribution limits apply, so be sure to research these options carefully.
  • Medicaid: This government program provides health insurance for low-income individuals and often covers braces for children in certain situations. Conditions and limitations vary by state. Check with your state’s Medicaid program for specific details.

Keep in mind: Medicaid coverage for adults with braces is limited and varies significantly between states. Some states might offer coverage in specific situations, while others might not cover braces for adults at all. It’s crucial to understand your state’s rules and if providers like Smilebliss accept Medicaid coverage.

Choosing Between In- and Out-of-Network Orthodontists

Figuring out how your dental insurance covers braces with different orthodontists, especially when you’re looking at in-network versus out-of-network options, can get a bit complex.

Here’s a breakdown to make things clearer:

In-Network Coverage

Your insurance plan has a list of orthodontists they prefer, known as in-network providers.

These providers have special agreements with your insurance company, usually including lower fees. If you go with an in-network orthodontist, you’ll likely get more of your treatment covered and save some money.

Out-of-Network Coverage

If you decide on an out-of-network orthodontist, keep in mind that your insurance might cover less of your treatment, and you’ll end up paying more out of pocket. This is because out-of-network providers don’t have the same fee agreements with your insurance.

  • Paying More Upfront: Going out-of-network often means you’ll face higher costs directly. Insurance plans have set fees they’ll cover for services, but out-of-network orthodontists can charge more than those amounts. You’ll need to cover the difference, which can add up.
  • Dealing with Braces Reimbursement: Sometimes, seeing an out-of-network orthodontist means you’ll have to pay the entire bill upfront and then ask your insurance to pay you back. The amount you get back depends on your insurance plan’s rules for out-of-network care.

It’s important to dig into the details of your insurance plan to understand how it handles out-of-network orthodontists. 

Talking directly to your insurance provider can give you the most accurate information on what will be covered, how reimbursements work, and if there are any additional costs you need to know about when choosing an out-of-network orthodontist.

Managing the Cost of Braces without Insurance

Braces aren’t cheap, and their cost can depend on many things, including the type, how complex your treatment is, and where you live. Traditional braces usually cost between $3,000 and $7,000, and treatments like clear aligners might cost $4,000 to $8,000 or more.

Paying for braces without insurance can be tough, but there are options to make it easier. Many orthodontists offer payment plans and financing, and you might qualify for discounts or help from government programs or charities.

At Smilebliss, our goal is to provide a great smile in less time for less money. Our braces cost $2,998, and clear aligners are $3,998. We offer affordable payment plans for $123 per month.

Here are some suggestions for dealing with the cost of braces:

  • Payment Plans: Talk to your orthodontist about making small payments over time or low-interest financing options. This can make the cost of braces more manageable by spreading it out.
  • Discounts or Scholarships: Some orthodontists offer discounts or scholarships to patients who can’t afford the full cost. Reach out to different orthodontists in your area to see if they offer such programs.
  • Charitable Programs: There are charities out there that can help with the cost of braces. Each one has different rules about who they help and what they can pay for, but it’s worth looking into.
  • Insurance or Discount Plans: There are also insurance plans and discount programs out there that cover some of the cost of braces. Getting dental insurance can lower what you have to pay directly, while discount plans can get you lower prices on all kinds of dental care for a monthly or yearly fee.
  • Choose an Affordable Provider: Not all orthodontists charge the same for treatment. An affordable practice like Smilebliss charges up to 60% less than others.

It’s always a good idea to talk to a professional about your dental care. A dental care provider can look at your specific needs and tell you what treatments would work, and they can help you figure out a plan for dealing with the cost.

Smile with Confidence, Smile with Smilebliss

Getting a perfect smile shouldn’t be complicated or expensive. At Smilebliss, we make it easy and affordable.

  • Maximize Your Insurance Benefits: Our team helps you understand and utilize your dental insurance to its fullest.
  • Transparent Costs & Flexible Plans: It’s a place where everyone can get a great smile in less time for less money— up to 60% less. We offer clear pricing and flexible payment plans to fit your budget.
  • Expert Guidance: Our experts are with you every step of the way, navigating insurance and treatment options.

Invest in your smile with Smilebliss. Book your appointment today!

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