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You know the drill: present your insurance card, pay your copay, and go about your day. It’s how many of us handle most of our medical transactions. But orthodontic treatment is a different ball game. Getting coverage for your orthodontic treatment depends on a few different factors, primarily whether your benefits include teledentistry coverage.
This can play out a few different ways, depending on your particular insurance provider and plan. It’s possible that your insurance will cover 50% of your SmileDirectClub treatment. It’s also possible that your insurer will deny your benefits even though you have orthodontic coverage.
That’s why we created this guide. Read on for an in-depth look at the policies and procedures involved with benefit claims for at-home orthodontic treatment with SmileDirectClub.
Does Standard Insurance Cover Orthodontics?
What If My Benefits Are Denied?
What About HSA and FSA?
Does Standard Health Insurance Cover Orthodontics?
In short: no, it doesn’t. And this is normally the case whether you’re considering a traditional orthodontic treatment option like braces, or an at-home option like SmileDirectClub. Health insurance plans are separate from dental insurance plans, so they’ll usually only cover serious, medically necessary procedures on the face and jaw. Standard health insurance does not cover routine cleanings, fillings, and orthodontic work.
And if routine dental care isn’t covered, at-home teeth straightening certainly isn’t. Insurance providers often consider it a cosmetic treatment, not medically necessary, so if you just have standard health insurance, you’ll probably be stuck with the full bill.
What If I Have Dental Insurance?
You can pair dental insurance with standard health insurance to cover preventative care (like semiannual cleanings) and other routine procedures, such as fillings, root canals, etc.
Sometimes these plans will include orthodontic benefits as well, and that’s where you should focus. Orthodontic benefits often come with a lifetime coverage limit (rather than an annual limit). So, if your teeth require extensive or long-term treatment, you might run out. And there are a few other complications:
On average, orthodontic benefits could cover 50% of the treatment cost up to your lifetime maximum, and a deductible could also apply.
Some dental benefits have a waiting period, which means you’ll need to wait a predetermined amount of time after enrolling with your plan before using them (this could be 3–6 months for minor procedures and 6–12 for major ones).
Other plans have age restrictions. For example, some only cover orthodontic treatment for dependents up to age 19.
You should know the distinction between “in-network” and “out-of-network” coverage. Treatment by out-of-network providers can be subject to higher deductibles, and may also receive less coverage. Home-based treatment options, when covered, are Teledentistry services that are usually considered out-of-network.
The moral of the story is that you shouldn’t simply assume your dental insurance will cover SmileDirectClub, or any orthodontic treatment, for that matter. Familiarize yourself with your plan’s details and work with SmileDirectClub to see if you’re eligible for coverage.
Is SmileDirectClub Covered Differently Than Braces or Invisalign?
Next scenario: you have dental insurance and orthodontic benefits. Will you receive coverage for SmileDirectClub treatment? Surprisingly, not always.
With SmileDirectClub, a certified dentist or orthodontist in your state will approve and supervise your care remotely, rather than in person. Some dental insurers treat SmileDirectClub just like in-office options like braces or Invisalign and provide coverage accordingly. However, because SmileDirectClub does not involve regular, in-person check-ups, certain insurers incorrectly consider it a “do-it-yourself” treatment and routinely decline to provide coverage.
It’s important to distinguish between home aligners and the recent concerning trend of DIY orthodontics. The latter stems from online videos where people attempt to shift their own teeth using rubber bands and other crude materials, which can severely damage your teeth and gums. At-home treatment through a provider like SmileDirectClub is designed and monitored by a licensed dentist or orthodontist, so it doesn’t present the same risks.
Time for the question that’s no doubt on your mind: does my insurance company cover home aligner treatment? Fortunately, SmileDirectClub partners with a few big-name insurance companies. These are the ones with a good track record of supporting them:
Blue Cross Blue Shield
Even if you have a different provider, your treatment might be covered. Although there are other companies that aren’t as likely to cover at-home aligners.
Note that this is a rapidly changing situation. Many insurers have recently updated or are currently updating their policy on coverage for home-based orthodontic treatment. We will continue to update this list as we learn about these changes.
How Do I Find Out Whether I Have Coverage?
On their insurance page, SmileDirectClub allows you to enter your insurance plan information. They will inquire with your insurance company and contact you by email or text to let you know whether you’re eligible for coverage.
Some online reviewers report situations where a SmileDirectClub representative told them they would receive insurance coverage, but their provider still denied the request. Just like other medical or dental insurance claim processes, the insurer can initially deny the claim for various reasons, often ones with easy remedies. In these cases, however, it appears that the customer had to handle insurance disputes on their own, although SmileDirectClub responded to their complaints on social media and review sites and, we assume, continued the conversation privately.
How Do I Claim My Insurance Benefits?
If SmileDirectClub’s support team determines that you can receive coverage, they will prepare the claim paperwork for you. All you need to do is fill out some personal information and send it to your insurance provider.
The tricky part is that SmileDirectClub won’t provide you with an ADA claim form until there’s a dentist assigned to your case, since the form requires dentist information. However, they won’t assign you a dentist until you’ve paid for their treatment. Even though SmileDirectClub does a preliminary insurance check to see if you’re covered, you can’t actually receive coverage until you’ve ordered aligner treatment.
According to their website, “in most cases, SmileDirectClub will coordinate payment directly with the insurance company so you only pay the balance of what you owe after discounts and insurance coverage is applied to the total cost of your treatment.” However, some companies might provide a reimbursement instead. In this situation, you would pay for the aligners upfront (or sign up for a payment plan) and then receive a reimbursement check from the insurance company. Sometimes this reimbursement comes in one lump sum and other times it’s dispersed throughout your treatment.
What If My Insurance Company Denies My Benefits?
Let’s say SmileDirectClub does their preliminary check and determines that your insurance company won’t cover their aligners. Or SmileDirectClub determines you will receive coverage, but your insurance company denies your claim. Then what?
Both are very real situations for some SmileDirectClub customers. The company is doing its best to forge new partnerships with insurance companies, but customers can still have trouble getting coverage.
First, you’ll want to contact your insurance company. It’s not uncommon for insurers to deny claims even if they typically cover teledentistry. If you made a mistake in your paperwork or the insurance agent didn’t recognize the type of treatment, that’s enough for a denial. By calling them, you can clarify the treatment details and potentially work it out.
Another option is to appeal the insurer’s decision. According to Healthcare.gov, you may request an internal appeal (a re-review by the insurer) within 180 days or an external appeal (a review by the state) within four months. Appeals, however, are often complicated, and SmileDirectClub doesn’t openly offer to help with the process.
If that doesn’t work, you might consider enrolling in SmileDirectClub’s financing plan, SmilePay, to help make your payments more manageable. Or, you can apply for CareCredit, a line of credit with flexible payment plans specifically intended for medical expenses.
What About HSA and FSA?
Flexible Spending Accounts (FSAs) and Health Savings Accounts (HSAs) both allow you to contribute pretax income to your medical expenses. They’re an option for many employer health plans (HSAs require a high-deductible plan, though), and they’re also a viable payment option for your SmileDirectClub treatment. Whether or not you’re eligible for insurance coverage, this can be a great way to help cover the cost of your treatment.
SmileDirectClub accepts payments from FSA and HSA accounts. If your plan has a specific debit card, just process it like you would any other card. Otherwise, contact their customer support team for assistance.
If you have an FSA, remember that they have a time limit, since you can’t roll over funds from year to year like you can with an HSA. Make sure to use your funds before they expire!
The number one takeaway: check with your insurance provider before starting treatment, because it can knock up to 50% off your treatment cost! But even though some SmileDirectClub customers are eligible for insurance coverage, it depends on your provider and plan.
If you’re unsure and don’t want to start the process with SmileDirectClub just yet, you can always reach out to your insurer directly. Once you’ve got that squared away, you’ll have a better sense of your total SmileDirectClub price and one step closer to beginning your smile journey.
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Pursuing orthodontic treatment as an adult can feel stressful and overwhelming. At Smile Prep, we strive to make the process as easy as possible for our readers. Our guides and reviews cut the fluff and give you the information necessary to take a confident step toward your smile goals.
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Smile Prep is not affiliated with or sponsored by SmileDirectClub in any way. In the interest of transparancy, we maintain a disclosure page that outlines our affiliate policies and practices. Views and opinions expressed in this article are ours alone.
February 28, 2021 at 10:15 pm
I actually have Aetna pod II and delta dental with my employer should I check both for coverage
March 19, 2021 at 4:49 pm
Hi Tiana – yes, I think it would definitely be worth asking about coverage for both providers. I’m not familiar with the specifics of the Aetna pod II plan, but it is my understanding that some Aetna plans do offer coverage for SmileDirectClub. Delta Dental typically does not provide coverage for at-home aligners, but since plans are all different from state to state, I’d definitely double check. If your Delta Dental plan is through your employer, you may have the best success asking the designated plan administrator within your company for details.
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Does Standard Insurance Cover Orthodontics?
Is SmileDirectClub Covered Differently?
What If My Benefits Are Denied?
What About HSA and FSA?
Concerned About the Cost of Orthodontic Treatment?
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