Braces and Dental Coverage

Dental Insurance & Orthodontic Benefits

Many parents wince when they realize their child will need braces. The average cost of braces, according to the American Dental Association’s 2018 Annual Survey, ranges from $5,000 to $6,000, though it should be remembered that many factors can affect the total cost. These factors include not only the circumstances of the patient’s dental situation, the type of braces used, but also the region in which the patient receives orthodontic care. In Manhattan, for example, braces might cost as much as $11,500.

Braces are a form of orthodontic service. Orthodontics, a sub-discipline within the field of dentistry, provides treatment for patients not only with improperly aligned teeth but also improperly aligned jaw or bite patterns. In this article, the following topics will be reviewed to help you with your questions about orthodontry benefits within dental coverage:

• Types of braces and price implications
• Do braces cost more for adults?
• Other orthodontic services
• Dental insurance and orthodontic benefits
• How to confirm orthodontic coverage

Types of Braces & Price Implications

Braces have evolved with the times and now there are several kinds of braces available as opposed to a few generations ago when people were essentially limited to metal braces or nothing. The four main categories of braces are:

• Traditional braces
• Invisalign braces
• Ceramic braces
• Lingual (a.k.a. “invisible”) braces

Traditional braces are the metal variety with which most people are familiar. Generally this brace type is considered to be the least expensive of the four mentioned above. Ceramic braces, which look like traditional braces but are transparent, are slightly more expensive. Invisalign braces are clear plastic shells that fit directly over the teeth. Costs vary by circumstances but the Invisalign website provides multiple cost scenarios ranging from $3,400 to $7,100. Less common in the United States than Europe, lingual braces are metal braces that attach to the back side of the teeth and, therefore, are invisible. Consumers who decide to use lingual braces should expect to pay more than the traditional meta version. The OralB webpage devoted to brace costs lists the price range for this option between $8,000 and $10,000.

For more detailed information on your options for braces, see our article “Orthodontics.”

Do Braces Cost More for Adults?

While braces are associated with childhood, adults can also wear braces to improve their smiles. Braces applied to adults may take longer to straighten teeth and may require a longer treatment period. A longer treatment period, in turn, may mean higher costs for the patient.

Other Orthodontic Services

Orthodontic services extend beyond merely the installation and maintenance of braces. They also include surgical options to address severe jaw alignment issues. Palatal expanders, which expand the size of the upper jaw in a child’s mouth and reduce crowding among teeth, are another service covered under orthodontry (palatal expanders are also used for adults but less commonly).

Dental Insurance and Orthodontic Benefits

Many dental plans do not have coverage for services provided by an orthodontist. However, by reviewing a dental plan’s summary of benefits (or plan brochure), you should be able to quickly identify if orthodontics are covered and under what conditions (including waiting periods). Below are a few examples of benefit conditions observed in various dental plans offered in multiple states. They illustrate the lack of uniformity among orthodontic benefits and the need for careful shopping on the part of consumers.

Example 1

• Orthodontic benefits are only available for eligible dependent children up to the age of 19
• Coverage of costs
  • 1st Year – 10%
  • 2nd Year – 25%
  • 3rd Year – 50%
• $1200 lifetime maximum per person

Example 2

• Orthodontic benefits are available to all ages under this plan
• In-network coverage:
  • 1st year of insurance enrollment - Not covered service
  • 2nd year of insurance enrollment and after – 50% after deductible
• Out-of-network coverage:
  • 1st year of insurance enrollment – Not covered service
  • 2nd year of insurance enrollment and after – 40% after the deductible is satisfied
• $1000 lifetime maximum
• Orthodontia – 12-month waiting period

Example 3

• Orthodontic benefits are only available for eligible dependent children up to age 19
• 1st year of insurance enrollment – 10%
• 2nd year of insurance enrollment – 25%
• 3rd year of insurance enrollment – 50%
• $1200 lifetime maximum per person for this benefit

Example 4

• 1st year of insurance enrollment – 0% (Not covered services)
• 2nd year of insurance enrollment – 50% after $150 Lifetime Orthodontia Deductible up to $300 calendar year maximum and $1500 Lifetime Maximum per eligible dependent child
• 3rd year of insurance enrollment and after – 50% after $150 Lifetime Orthodontia Deductible up to $300 calendar year maximum and $1500 Lifetime maximum per eligible dependent child

As demonstrated in a couple of the above examples, a dental plan that offers orthodontic coverage may use a “waiting period” that delays the benefit’s availability for a year.

How to Confirm Orthodontic Coverage

Given the irregular coverage of orthodontic services, a consumer can’t enroll in a dental plan and hope for the best with respect to orthodontic coverage. Instead, he or she must confirm not just the presence of orthodontic coverage but the specific details of that coverage. This can be accomplished several ways. First, the consumer can investigate the specific conditions of the dental plan using one of the following resources:

• An online “plan details” button
• A summary of benefits
• A plan brochure

If these resources aren’t available or have vague information, the consumer can also use the customer service number for the website providing the dental information they are reviewing.