Orthodontic Benefits

Orthodontic treatment refers to the branch of dentistry that deals with the alignment of the teeth with braces and retainers. Benefits are provided for covered orthodontic expenses and are reimbursed at 50 percent with a lifetime maximum of $1,500. If expenses exceed this $1,500 lifetime maximum, this plan will not pay the additional costs. These expenses are not subject to the $200 annual deductible or $2,300 annual coinsurance maximum.

If orthodontic treatment is terminated for any reason before completion, benefits cease at that time. If treatment is resumed, benefits (to the extent remaining in the original treatment plan) will be resumed. Benefits for orthodontic services are for those months the patient is eligible.

Covered orthodontic services include the following:

• Orthodontic examinations.
• Bands and the placement of the bands.
• Monthly adjustments to the bands.
• Preliminary studies.
• Cephalometric radiographs.
• Diagnostic casts.
• Retainers and retainer devices.

How Orthodontic Benefits Are Calculated

Patient Is Eligible At  Banding

If the patient is eligible for benefits when the bands are placed, covered expenses for the initial placement of the bands are reimbursed at 50 percent up to a maximum of $750 or one-third of the total cost of the orthodontic treatment plan, whichever is less. The remaining orthodontic expenses are reimbursed as continuing treatment expenses.

Patient Is Not Eligible At Banding

If the patient is not eligible when the bands are placed, covered expenses that would have been considered had the patient been eligible are deducted from the total cost before the continuing treatment benefit is calculated.

If the orthodontist does not separate banding expenses from other orthodontic expenses, banding expenses are assumed to be one-third of total orthodontic expenses or $1,500, whichever is less. The remaining orthodontic expenses are reimbursed as continuing treatment expenses.

Continuing Treatment Expenses

Continuing treatment expenses are the charges for monthly adjustments to the bands. The monthly benefit amount is determined by dividing the total continuing treatment expenses by the number of months in the treatment period established by the orthodontist at the time of the placement of the bands. Covered continuing treatment expenses are reimbursed at 50 percent. Once the monthly continuing treatment benefit has been determined, it cannot be recalculated, even if the treatment period is extended. Claims must be for services and supplies already provided.

Exclusions – Orthodontic Benefits

Benefits are not provided for:

1. The replacement or repair of orthodontic retainers.
2. Habit breaking appliances or patient management problems.
3. Broken or missed appointments.
4. Charges for completing or submitting forms, including medical records or reports.
5. All other services or supplies not specifically covered under orthodontic benefits.
6. Services or supplies subject to General Limitations and Exclusions.