Download Providing Coverage for Orthodontics

Providing coverage for orthodontics
Orthodontics is a dental specialty that treats the misalignment of teeth. For orthodontic treatment, one of the
following can apply for plans with orthodontic coverage. The benefits will vary depending on the circumstances.
Patient is in
active
orthodontic
treatment
New employee (new hire)
(Member’s effective date with Aetna differs from the plan
sponsor’s effective date with an Aetna Dental® plan.)
Current employee
(Member’s effective date with Aetna is the same as the plan
sponsor’s effective date with an Aetna Dental plan.)
Definition
Work in progress
Takeover
Scenario
The employee is hired by company XYZ. If the treatment started
before Aetna coverage began under company XYZ, the entire
treatment will be considered work in progress.
Company XYZ chooses Aetna as their new insurance carrier. If the
treatment started before coverage began with Aetna, and the treatment
was covered by the old plan, this will be considered a takeover. We will
continue to cover the treatment. In order to process claims for takeover
orthodontic treatment, we need a claims form with the total treatment
plan information as well as the amount paid by the previous insurance
carrier.
Example
For example, the treatment will last 24 months and cost $4,000.
In October, the member switches employers. The new employer
offers Aetna Dental insurance with an orthodontic rider, covering
treatment at 50 percent with a $1,500 lifetime maximum. The
Aetna Dental plan will help cover the remaining eligible
treatment months under the new plan. In this case, the plan will
pay $62.50 per month. If there are 20 treatment months
remaining, that would mean a $1,250 benefit.
For example, the treatment will last 24 months. Effective January 1,
the employer switches to an Aetna Dental plan. For patients in active
treatment, we will cover the remainder of the treatment starting with
the Aetna Dental plan’s effective date.
Just remember, some plans have a work-in-progress exclusion.
That means no benefits will be paid for treatment that began
before the new plan’s effective date. However, members are
eligible for their full orthodontic benefits for future care.
We will apply the normal payment schedule for the Aenta Dental plan.
In this case, we calculate that we should be paying $62.50 per month.
There are 20 months remaining, so that would mean a $1,250 benefit.
However, the previous carrier had already paid $950, and the plan has a
$1,500 lifetime maximum benefit, so we would pay the remaining $550.
Please note: In this same example, if there are only 2 months of
eligible treatment remaining, we would pay $125 ($62.50 for each
month) — even though there is $550 available in the plan maximum.
The member would then have $425 remaining for any future eligible
orthodontic treatment. This is regardless of any outstanding balance
the member may have ­­with the orthodontist.
New employee (new hire)
Current employee
Orthodontic treatment ended
before dental coverage with Aetna
began
No benefits will be available for the treatment that already
ended. However, the member will have orthodontic benefits for
future eligible treatments.
No benefits will be available for the treatment that already ended. Any
amount paid by the previous carrier will be updated to the Aetna Dental
plan orthodontic maximum and is no longer available for future
orthodontic treatment.
Orthodontic treatment will start
after coverage with Aetna begins
As long as the treatment begins after the Aetna Dental coverage
begins, the patient will have the full orthodontic plan maximum
available.
As long as this date is after the Aetna Dental plan’s effective date (and
the patient has not had prior treatment), the patient will have the full
orthodontic plan maximum available.
Dental insurance uses the “banding date” (the date that braces are placed on the teeth) as the date the treatment starts. In order to process
claims for treatment, we need a claims form with the total treatment type, fee and estimated length of treatment.
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Frequently asked questions about orthodontic treatment and benefits
Q: How will the orthodontic treatment be
covered?
Q: How can we make sure a takeover goes
smoothly?
A: Orthodontics is split up into different phases
and dentitions. While most plans cover all
orthodontic phases and dentitions, please
see your plan booklet for coverage levels
and details.
A: T
o ensure a smooth transition with no
interruption in benefits payment (if
applicable), we need a claims form with
information about the total treatment plan as
well as the amount the previous insurance
paid. For details, please see your HR
representative or Aetna account manager.
Q: The member’s current employer is acquired
by another group that already uses Aetna
Dental. What will happen to the coverage
for the treatment that is in progress?
A: As long as both plans cover the treatment,
this would be considered a takeover.
Q: The member had an exam, molds and X-rays
done, but braces have not been placed yet.
Will Aetna cover the diagnostics?
A: Orthodontic diagnostics are covered. If a
nonparticipating dental provider performs
the diagnostic services, benefits will be
considered once the services are completed.
If a participating dental provider performs
the services, the charge for the diagnostics
treatment is included in the contracted rate
for the entire treatment plan. These would
not be considered separately.
Q: Will Freedom-of-Choice plan switches affect
the orthodontic benefits?
A: F reedom-of-Choice dental plans allow the
member to switch between a DMO plan and
an alternate plan (either PPO or indemnity)
on a monthly basis. We will use our regular
orthodontic calculation to determine the
monthly installment amount.
•D
MO to PPO/indemnity:
If a member switches from a DMO into an
indemnity or PPO, benefits are subject to the
new plan’s (indemnity or PPO) orthodontic
maximum. If that new plan doesn’t cover
orthodontia, no benefits can be paid. If a
member then switches back to the DMO,
the month(s) they were under the indemnity
or PPO get deducted from the calculations
and no benefits are paid for that time period.
• PPO/indemnity to DMO:
If a member or employer plan switches into
a DMO plan from an indemnity or PPO plan,
benefits are not subject to the indemnity or
PPO plan orthodontic maximum. The DMO
plan of benefits will be used to consider
remaining orthodontic treatment. However,
the patient is only permitted one course of
treatment totaling 24 months under the
DMO plan. Therefore, benefits for the
remaining orthodontic treatment will be
considered as one course of treatment
totaling 24 months under the DMO and
PPO plan.
Q: C
an a member continue to use the same
orthodontist if the plan is switched to a DMO
plan (either because this is a new plan, or
because of a Freedom-of-Choice switch)?
A: We allow members to stay with the current
orthodontist for treatment that is in progress
at the time the plan switched. For eligible
treatment, the member will receive the DMO
in-network benefits level.
Q: Do age limits affect the orthodontic benefits?
A: Your plan may have one or both of the
following age limits:
• Orthodontic age limit. When the plan
includes an orthodontic age limit, the
patient must be banded (that is, the braces
must be placed) before the patient reaches
this age limit
• Dependent age limit. The orthodontic
benefits will be available until the
dependent reaches the limiting age. Please
see the plan booklet for the plan’s limiting
age for dependents. No benefits would be
paid after this age limit is reached, even if
the treatment is ongoing.
If the plan includes both age limits, the patient
would have to be banded before the orthodontic
age limit and benefits would not be paid after
the patient reaches the dependent age limit.
In Idaho, dental benefits and dental insurance plans are offered and/or underwritten by Aetna Life Insurance Company. In all other states, dental benefits and dental
insurance plans are offered and/or underwritten by Aetna Health Inc., Aetna Dental of California Inc., and/or Aetna Life Insurance Company. In Texas, the Preferred
Provider Organization (PPO) insurance plan is known as the Participating Dental Network (PDN). Each insurer has sole financial responsibility for its own products.
This material is for information only and is not an offer or invitation to contract. An application must be completed to obtain coverage. Rates and benefits vary by location. In Colorado, this
policy DOES NOT include coverage of pediatric dental services as required under federal law. Coverage of pediatric dental services is available for purchase in the State of Colorado, and can
be purchased as a stand-alone plan, or as a covered benefit in another health plan. Please contact your insurance carrier, agent or Connect for Health Colorado to purchase either a plan that
includes pediatric dental coverage, or an Exchange-qualified stand-alone dental plan that includes pediatric dental coverage. In Virginia, the DMO plan is known as the Dental Network Only
plan (DNO). DNO in Virginia is not an HMO. To receive maximum benefits, members must choose a participating primary care dentist to coordinate their care with network providers.
Dental benefits and insurance plans contain exclusions and some benefits are subject to limitations or visit maximums. Providers are independent contractors and are not agents of
Aetna. Provider participation may change without notice. Aetna does not provide care or guarantee access to dental services.
While this material is believed to be accurate as of the production date, it is subject to change.
Policy form numbers issued in Oklahoma and Idaho include: GR-9/GR-9N, GR-23 and/or GR-29/GR-29N.
©2016 Aetna Inc.
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