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Orthodontic benefits
Orthodontic (or “ortho”) services are used to correct misaligned teeth. Your coverage for these treatments depends on the plan offered by your employer or organization.1
The three examples below are based on the following:
How will orthodontic services be paid?
Your orthodontist should submit a claim to us for service that starts on or after the member’s effective date. Payment will be based on your group’s orthodontic payment schedule and will continue until the treatment ends or you have reached your lifetime orthodontic maximum benefit. Note that if the policy terminates before treatment ends, payments will stop on the last date of coverage.
How much will orthodontic treatment cost?
Ask your orthodontist to request a pre-determination of benefits estimate from Delta Dental. You’ll receive an estimate of the treatment cost showing your share of the cost and how much Delta Dental will pay.
Do I submit the claim for orthodontic services?
When you use a Delta Dental network orthodontist, the dentist will submit claims on your behalf when the braces are first placed or an appliance is first delivered. However, if you choose an out-of-network orthodontist, you may need to submit a claims form yourself to Delta Dental for reimbursement. When switching insurance during treatment, ask your dentist to submit the original claim under your new insurance policy and we will prorate the payments.
My orthodontist has recommended tooth extractions before treatment. Is that covered?
For some plans, those services would be covered under your Basic or Major oral surgery benefit, and the cost would count towards your annual maximum and would not be applied towards your orthodontic lifetime maximum.
My orthodontist has recommended “two-phase” orthodontic treatment, beginning while my child is quite young (phase I) and completed at a later date (phase II). Is two-phase orthodontic care covered?
Yes; however, the total amount covered for both phases will be limited to the lifetime orthodontic maximum, and you will be responsible for any costs not paid by Delta Dental.
My plan has a lifetime maximum benefit for orthodontics. Is orthodontics subject to the annual maximum?
For most plans, covered orthodontic services only count against the orthodontic lifetime maximum. This represents the total amount the plan will pay for covered orthodontic services.
Are Invisalign® braces covered by my plan?4
Currently all plans that cover orthodontic services cover Invisalign up to the orthodontic lifetime maximum benefit. Patients opting for Invisalign Treatment could have additional Out-of-Pocket Expense with Invisalign Treatment.
1Your benefits may differ from the general information provided here. Review your plan booklet for specific details regarding your plan’s orthodontic benefits, deductibles, maximums, waiting periods, limitations, and exclusions. These benefits apply to services provided by Delta Dental PPO™, Delta Dental Premier®, Delta Dental PPO Plus Premier™ and Delta Dental Advantage network participating dentists.
2Does not apply to Flagship or DeltaCare® USA plans.
3Orthodontia for minor tooth movement is not covered.
4Orthodontic treatment must be performed by a licensed dentist acting within the scope of applicable law. The dentist of record must perform a clinical evaluation of a patient and have all necessary diagnostic information related to a specific patient’s treatment.
All you need to know about Delta Dental orthodontic benefits2
What’s covered?
Your coverage depends on your group’s specific plan.3 Most Delta Dental plans include coverage for:
Your coverage depends on your group’s specific plan.3 Most Delta Dental plans include coverage for:
- Pre-orthodontic treatment visit
- Examination and start-up records
- Comprehensive orthodontic treatment
- Orthodontic retention is included in Comprehensive Treatment. Replacement retainers are not covered.
What if treatment began under a different insurance policy?
Work-in-progress may be covered for patients undergoing active orthodontic treatment. Please submit an orthodontic treatment claim to us that includes submitted charge, payments by prior carrier, treatment plan, and other coverage information if it applies.
Work-in-progress may be covered for patients undergoing active orthodontic treatment. Please submit an orthodontic treatment claim to us that includes submitted charge, payments by prior carrier, treatment plan, and other coverage information if it applies.
Do I have to see a Delta Dental orthodontist?
Enrollees can visit any licensed orthodontist; however, out-of-pocket costs may be lower if you use a Delta Dental network orthodontist. Delta Dental’s payment is made directly to in-network dentists. For out-of-network dentists, Delta Dental’s payment would be made to the member.
Enrollees can visit any licensed orthodontist; however, out-of-pocket costs may be lower if you use a Delta Dental network orthodontist. Delta Dental’s payment is made directly to in-network dentists. For out-of-network dentists, Delta Dental’s payment would be made to the member.
Orthodontic payment examples
The three examples below are based on the following:
- Orthodontia benefit provides 50% coinsurance up to a $1,500 lifetime maximum
- Treatment plan duration is 24 months
- Approved orthodontist fee is $6,000
Example 1 - New ortho patient
Treatment begins on or after the effective date of coverage.
Treatment begins on or after the effective date of coverage.
| Orthodontist approved fee | $6,000 |
| Lifetime maximum | - $1,500 |
| Patient responsibility | $4,500 |
| Delta Dental pays | |
| Lifetime maximum | $1,500 |
| 24-month treatment plan | ÷ 24 |
| Delta Dental monthly payment | $62.50 |
Example 2 - Work in progress
Treatment began prior to effective date of coverage, and benefits are pro-rated for the number of months remaining in treatment. Patient completed 14 months of treatment prior to being enrolled, leaving 10 months for Delta Dental’s portion of the treatment plan.
Treatment began prior to effective date of coverage, and benefits are pro-rated for the number of months remaining in treatment. Patient completed 14 months of treatment prior to being enrolled, leaving 10 months for Delta Dental’s portion of the treatment plan.
| Orthodontist approved fee | $6,000 |
| Lifetime maximum | - $1,500 |
| Patient responsibility | $4,500 |
| Lifetime maximum | $1,500 |
| 24-month treatment plan | ÷ 24 |
| Monthly payment | $62.50 |
| Delta Dental | |
| 10 months | 10 |
| Monthly payment | X $62.50 |
| Total Delta Dental payment | $625 |
Example 3- Work in progress
Treatment began prior to effective date of coverage (work-in-progress), and the prior carrier paid $900 of the $1,500 lifetime benefit. Delta Dental will pay the remaining $600 over the next 10 months until a full $1,500 has been paid between the prior carrier and Delta Dental.
Treatment began prior to effective date of coverage (work-in-progress), and the prior carrier paid $900 of the $1,500 lifetime benefit. Delta Dental will pay the remaining $600 over the next 10 months until a full $1,500 has been paid between the prior carrier and Delta Dental.
| Orthodontist approved fee | $6,000 |
| Lifetime maximum | - $1,500 |
| Patient responsibility | $4,500 |
| Lifetime maximum | $1,500 |
| 24-month treatment plan | ÷ 24 |
| Monthly payment | $62.50 |
| Prior carrier | |
| Total prior carrier payment | $900 |
| Delta Dental | |
| 9 months | 9 |
| Monthly payment | X $62.50 |
| $562.50 | |
| One partial payment | + $37.50 |
| Total Delta Dental payment | $600 |
FAQs
How will orthodontic services be paid?
Your orthodontist should submit a claim to us for service that starts on or after the member’s effective date. Payment will be based on your group’s orthodontic payment schedule and will continue until the treatment ends or you have reached your lifetime orthodontic maximum benefit. Note that if the policy terminates before treatment ends, payments will stop on the last date of coverage.
How much will orthodontic treatment cost?
Ask your orthodontist to request a pre-determination of benefits estimate from Delta Dental. You’ll receive an estimate of the treatment cost showing your share of the cost and how much Delta Dental will pay.
Do I submit the claim for orthodontic services?
When you use a Delta Dental network orthodontist, the dentist will submit claims on your behalf when the braces are first placed or an appliance is first delivered. However, if you choose an out-of-network orthodontist, you may need to submit a claims form yourself to Delta Dental for reimbursement. When switching insurance during treatment, ask your dentist to submit the original claim under your new insurance policy and we will prorate the payments.
My orthodontist has recommended tooth extractions before treatment. Is that covered?
For some plans, those services would be covered under your Basic or Major oral surgery benefit, and the cost would count towards your annual maximum and would not be applied towards your orthodontic lifetime maximum.
My orthodontist has recommended “two-phase” orthodontic treatment, beginning while my child is quite young (phase I) and completed at a later date (phase II). Is two-phase orthodontic care covered?
Yes; however, the total amount covered for both phases will be limited to the lifetime orthodontic maximum, and you will be responsible for any costs not paid by Delta Dental.
My plan has a lifetime maximum benefit for orthodontics. Is orthodontics subject to the annual maximum?
For most plans, covered orthodontic services only count against the orthodontic lifetime maximum. This represents the total amount the plan will pay for covered orthodontic services.
Are Invisalign® braces covered by my plan?4
Currently all plans that cover orthodontic services cover Invisalign up to the orthodontic lifetime maximum benefit. Patients opting for Invisalign Treatment could have additional Out-of-Pocket Expense with Invisalign Treatment.
1Your benefits may differ from the general information provided here. Review your plan booklet for specific details regarding your plan’s orthodontic benefits, deductibles, maximums, waiting periods, limitations, and exclusions. These benefits apply to services provided by Delta Dental PPO™, Delta Dental Premier®, Delta Dental PPO Plus Premier™ and Delta Dental Advantage network participating dentists.
2Does not apply to Flagship or DeltaCare® USA plans.
3Orthodontia for minor tooth movement is not covered.
4Orthodontic treatment must be performed by a licensed dentist acting within the scope of applicable law. The dentist of record must perform a clinical evaluation of a patient and have all necessary diagnostic information related to a specific patient’s treatment.
Delta Dental of New Jersey is a part of Delta Dental Plans Association. Through our national network of Delta Dental companies, we offer dental coverage in all 50 states, Puerto Rico and other U.S. territories.
