Orthodontic Expenses | Dental Plan Design

With possibly a few exceptions, orthodontic benefits never are written without other dental coverage. Nonetheless, orthodontic benefits present a number of design peculiarities that suggest this subject should be treated separately.

Orthodontic services, unlike nonorthodontic procedures, generally are rendered only once in an individual's lifetime; orthodontic problems are unlikely to recur. Orthodontic maximums, therefore, typically are expressed on a lifetime basis. Deductibles, which are applicable only to orthodontic services, also are often expressed on a lifetime basis. However, it is quite common for orthodontic benefits to be provided without deductibles, since a major purpose of the deductible—to eliminate small, nuisance-type claims—is of little consequence.

Because adult orthodontics generally are cosmetic and also because the best time for orthodontic work is during adolescence, many plans limit orthodontic coverage to persons under age 19. However, an increasing number of plans are including adult orthodontics as well, and many participants are taking advantage of this feature.

The coinsurance level for orthodontic expenses typically is 50 percent, but it varies widely depending on the reimbursement levels under other parts of the plan. It is common for the orthodontic reimbursement level to be the same as that for major restorative procedures.

Reflecting the nature of orthodontic work, and unlike virtually any other benefit, orthodontic benefits often are paid in installments instead of at the conclusion of the course of treatment. Because the program of treatment frequently extends over several years, it would be unreasonable to reimburse for the entire course of treatment at the end of the extended time. It would be equally unreasonable to pay for the entire course of treatment at its beginning.