Orthodontia Summary

Overview: Orthodontia coverage is available on each dental plan. Plan A and Plan B offer coverage for children only. Plan A+ provides orthodontia coverage for adults as well as children. Plan payments will begin automatically to the party assigned on the claim form. The payout is made in equal quarterly installments not to exceed two years.

 

Orthodontic Treatment: Orthodontic treatment means the movement of teeth by means of active appliances to correct the position of maloccluded or malpositioned teeth.

 

Treatment program: Treatment program means an interdependent series of orthodontic services prescribed by a physician to correct a specific dental condition. A program will start when the active appliances are inserted. A program will end when the services are done, or after eight calendar quarters starting with the day the appliances were inserted, whichever is earlier.Please note: Plan A+ includes coverage for both adults and children. On Plan A and Plan B, the orthodontia benefit is available up until the dependent child’s 19th birthday. Since the average orthodontic program is 24 months, the child needs to be banded by their 17th birthday to receive the full 8 quarters of benefit.

 

Expenses: An expense is incurred:a. at the end of every quarter (three-month period) of a treatment for a person who pursues an orthodontic program, but not beyond the date the treatment ends, or b. at the time the service is rendered for a person who incurs covered expenses but does not pursue a treatment program.

 

Benefit Calculation: Benefits will be payable when a covered expense is incurred. The covered expenses are based on the estimated cost of the patient’s treatment program. Payments are pro-rated by quarter (three month periods) over the estimated length of the program, but not for more than eight quarters, and multiplied by the orthodontic benefit percentage (50%). The last quarterly payment for a treatment may be changed if the estimated and actual cost of the treatment differs.

 

Ineligible Orthodontia Expenses: Covered expenses exclude and no benefits will be paid for expenses incurred:

1. for an orthodontic treatment program which began on or after an insured’s 17th birthday. Not applicable to Plan A+.

2. for a treatment program which began before the insured became covered for Orthodontic Expense Benefits.

3. after the individual’s insurance for orthodontic benefits terminates.

4. for orthodontic treatment started prior to 12 month waiting period is satisfied for new enrollees. In this case, benefits will be prorated and may results in the full lifetime maximum not being released.