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Does Dental Insurance Cover Braces?

May 20, 2024

Have you ever wondered if your dental insurance will help with the cost of braces? Exploring dental treatments like braces can seem daunting, especially when it comes to understanding how insurance factors in. Braces do more than just improve your smile—they can also make a big difference in your dental health. So, the big question is: does dental insurance cover braces? 

How does Dental Insurance Cover Braces?

Yes, dental insurance can cover the cost of braces, but it depends on certain situations:

Dental coverage:

Your insurance plan needs to specifically mention that it covers orthodontic treatments like braces.

ACA plan for kids under 19:

An ACA plan might cover braces if a dentist says they're needed for health reasons.

Medicaid:

Some state Medicaid plans pay for braces if they're necessary for kids; for adults, only three states cover braces under Medicaid.

Even though 80% of Americans have dental insurance, not all plans include coverage for orthodontic treatment. Usually, insurance won't foot the entire bill for orthodontic work, leaving you with some costs to cover yourself. For instance, your insurance might pitch in for 50% of the costs up to a limit of $1000. So, if braces cost $6,000, you'd still need to cover $5,000 after your insurance contribution.

How does Dental Insurance Work for Braces?

Dental insurance and braces can get a bit complicated. Generally, dental insurance for braces will help with most of the treatment costs, especially for kids, or it might cover a percentage of the expenses up to a certain amount.

Orthodontic Services Covered By Dental Insurance

Your dental insurance plan might cover various orthodontic services, such as:

  • Check-ups and visits, including the first consultation and follow-ups
  • Orthodontic tests like X-rays, molds, photos, and films
  • Different types of braces, from metal ones, to clear aligners
  • Initial treatments like tooth extractions, if needed
  • Retainers to maintain your teeth alignment

However, there are things that dental insurance often doesn't cover, like 

  • the replacement or repair of devices such as retainers. 
  • Self-administered orthodontic treatments and 
  • jaw surgery may also not be covered under standard dental plans. 

It's important to check your insurance policy to understand what it covers regarding orthodontic care.

When Does Dental Insurance Cover Braces?

Dental insurance covers braces in specific situations. This often includes having group or family coverage that caters to children needing braces. Additionally, insurance may cover braces deemed medically necessary, as defined by state regulations or standard criteria.

Dental Insurance Coverage for Orthodontics

Most dental insurance plans focus on covering preventive care, root canals, fillings, crowns, and oral surgery. However, many Americans receive dental insurance through their job or a group plan, which usually includes partial coverage for orthodontic treatments. Some larger dental insurance companies even offer an optional add-on for limited orthodontic coverage for an extra fee.

Orthodontics Insurance

Orthodontic insurance isn't offered as a separate plan; it's usually an extra feature added to your existing dental coverage, requiring an additional premium. When you opt for orthodontic benefits, they often apply to all covered individuals under your plan. However, it's important to note that orthodontic coverage might only apply to your children's braces, so reviewing the policy for any exclusions is crucial.

Family Plans in the ACA Marketplace

Around 9% of Americans with private dental coverage get it through the health insurance marketplace. The Affordable Care Act of 2010 made it mandatory for health plans to include pediatric dental benefits, which cover orthodontic care if deemed "medically necessary." States determine these criteria but often refer to the guidelines provided by the American Association of Orthodontics (AAO).

Braces and other orthodontic treatments are typically available for individuals aged 19 and below who have significant issues like identifiable syndromes (such as cleft lip) or severe craniofacial deformities causing pain, suffering, or dysfunction. It's important to note that most plans do not cover braces for mild cases of crooked teeth or less severe situations.

Medicaid and Other Government Dental Programs

About 94 million Americans rely on government programs like Medicaid, Medicare, Medicare Advantage, CHIP (Children's Health Insurance Program), or TriCare for dental coverage, among other health benefits.

Each state has its own rules for adult dental services under Medicaid, and orthodontic treatments are typically only covered in three states. Medicaid tends to offer more coverage for children, but meeting the eligibility requirements can be quite strict. 

When Dental Insurance Doesn't Cover Braces?

It can be tough to find a standalone dental plan that covers adult orthodontic services fully or as much as you might expect. Even with the various insurance types mentioned earlier, dental insurance might not cover braces in the following situations:

  • You're an adult.
  • When the treatment doesn't meet the criteria for being medically or dentally necessary.
  • If you've already begun treatment under a different plan.
  • If you started treatment before the insurance's required waiting period had elapsed.

How to Pay for Braces with Insurance

If your insurer covers braces in Pearland, TX, they typically only pay for a portion of the costs. This can be a percentage of the treatment fees and a specific dollar amount allocated over your lifetime. Insurance companies may also impose limits on your treatments or appliances, such as providing only one retainer every six years.

In most cases, insurance usually covers around $2000 to $4000 of the total costs, with an additional $1000 to $1500 often seen. However, this amount is lower than the entire cost of braces from start to finish, especially if multiple treatment phases are involved. 

How to get Braces Covered by Insurance?

Here are steps to figure out if your insurance can cover braces and how to find a plan that includes this coverage.

Check Your Current Insurance

There are three ways to determine if your current insurance covers braces:

  • Talk to your HR department: They often have detailed knowledge about your dental insurance.
  • Contact your insurance company: Give them a call to ask about braces coverage and any specific rules or materials covered, like metal or ceramic braces.
  • Review your plan details: Look for coverage specifics, dollar limits, and any exclusions. It's still a good idea to talk to someone from your insurance provider to clarify any uncertainties.

Conclusion

Does dental insurance cover braces? Well, Orthodontic treatments like braces can be partly covered by insurance, but it's crucial to know that most plans have restrictions and won't cover the full cost. Before signing up for dental insurance, make sure you understand what braces coverage entails. Consider comparing the cost of premiums over 1-4 years during treatment versus the potential savings over your lifetime.

Typically, insurance covers a percentage of the cost (like 50%) up to a lifetime limit (such as $1,500), leaving you responsible for the rest. You might need to explore options like an orthodontist's payment plan, personal loan, or tapping into savings to bridge the gap. Don't forget to inquire about discounts for paying the entire cost upfront or other potential savings.

Ready to discover your best smile? Don't wait—book your appointment with Afroz Burges DDS, PA, TX, today! For new patients, dial 281-547-2632, and existing patients can reach us at 713-340-2889. Let's start your journey to a confident, radiant smile together!

FAQ

Do all dental insurance plans cover braces?

Not every dental insurance plan covers orthodontic treatments like braces. Coverage depends on the specifics of your insurance plan.

What factors influence insurance coverage for braces?

Several factors can affect insurance coverage for braces, such as age, the severity of your orthodontic needs, and the type of insurance plan you have.

Can adults get insurance coverage for braces?

While some insurance plans offer orthodontic coverage for adults, it's generally less common than coverage for children.

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