Orthodontic Lifetime Maximum — What Is It and How Does It Work?
Orthodontic lifetime maximum can cap how much money your dental plan will contribute to your braces or other orthodontic work over the course of your lifetime. In fact, a lifetime
maximum may apply to an individual or even to the entire family. It’s true that dental insurance and your orthodontic lifetime maximum can be confusing. But, our Sky Ortho team is handy at two Oklahoma City locations to help you navigate your policy.
Most importantly, there are benefits to going to a provider listed in your network because you can usually save on out-of-pocket costs. Your insurance can include PPO (preferred provider organization), a lower level participating provider which is not PPO, and non-PPO benefit levels. Every employer chooses their benefit level with the insurance company. In-network providers typically have a separate agreement with each insurance company on the maximum they charge for each service. As a result, many patients save at least $300 more than a patient who doesn’t participate in insurance.
Plus, not all plans pay a different fee for non-PPO providers. Many insurance companies will pay the same benefit regardless of the provider’s status. For this reason, it is a good idea to be familiar with all aspects of your policy, including an orthodontic lifetime maximum. When you are confused, discuss your questions with someone in finance at your orthodontic office.
Annual Maximum Versus Orthodontic Lifetime Maximum
Orthodontic treatment is nearly always a lifetime benefit and does not renew yearly. It is usually separate from your dental benefit but may include some oral surgery procedures.
The orthodontic insurance benefit is commonly a set dollar amount with a percentage. The insurance will pay for the % of treatment up to the lifetime maximum dollar amount whichever is less. For example, if your benefit is $1500 at 50% and your treatment fee is $400 it will pay 50% or $200. But if your treatment is $3000 or more, no matter how high the fee, the maximum you will receive is $1500.
Most insurance companies make an initial payment at appliance installation. Then, the insurance company makes payments until treatment is complete. They do this because your visits to the orthodontist occur over time. If you lose or cancel your insurance before treatment is complete, you will probably lose a portion of your benefit. For that reason, always check with your provider before canceling your insurance.
What Treatments Are Subject to an Orthodontic Lifetime Maximum?
Most of the time, lifetime maximums apply to specific services such as orthodontic treatment or dental implants. Even then, there may be exceptions. For example, sometimes orthodontic treatment is found to be medically necessary as opposed to cosmetic. Dental services like cleanings, regular checkups, fillings, crowns, root canals, and periodontal treatments are rarely limited over the course of a lifetime.
Another thing to keep in mind when it comes to the orthodontic lifetime maximum is that some orthodontic benefits have a longer waiting period than dental benefits. Even though you meet the waiting period for general dental benefits, you may have to wait 6-12 months longer before orthodontic insurance benefits are effective.
Also, if you have two orthodontic insurances, there is a coordination of benefits to see how these benefits work together. Usually, the birthday rule applies. For example, the coverage of the person whose birthday month and day come first is considered the primary coverage. If the plans coordinate properly, you will get the full benefit from both insurance companies. Again, Sky Ortho can help you understand how this works.
Some plans have no orthodontic lifetime maximum. Check the information for your plan to learn details.
When Does an Orthodontic Lifetime Maximum Reset?
Sometimes an orthodontic lifetime maximum is for the lifetime of one benefits plan only. In the event that you or your employer switches benefits companies, the lifetime maximum may reset or carry over.
In addition, the orthodontic lifetime maximum typically doesn’t follow child dependents when they outgrow dependent coverage. Children receiving orthodontic treatment may have a lifetime maximum as dependents under their parents’ dental plan. However, when they’re the primary member as adults, they usually have a new orthodontic lifetime maximum.
Let Us Help You with Braces in the OKC Area
At Sky Ortho, we are ready to help you improve your smile and navigate your insurance. If you have specific questions about orthodontic needs in the Oklahoma City area, our doctors are happy to visit with you, your loved ones, or friends. Give us a call or contact us at Sky Ortho.