Orthodontic Coverage with State-Sponsored Insurance Plans: What to Know

Your Insurance Questions Answered

• 1Does my dental insurance cover my orthodontic treatment? 

  If you have dental insurance, your plan may also offer orthodontic coverage. Diamond Braces will help you verify your insurance information and will work directly with your insurer to help secure coverage.

• 2Who does dental insurance cover?

  State-sponsored insurance plans offer orthodontic coverage to individuals under age 21. To receive the benefits, the patient's treatment must be approved according to state guidelines. Not all members will be approved, this is all depends on severity of so called malocclusion (dental condition of the bite and teeth).

• 3I am an adult over the age of 20. Will my state sponsored insurance cover my braces?

  State-sponsored insurance plans offer orthodontic coverage to individuals under age 21 and adult over the age limitation are not eligible for coverage. Don't let that stop you from having a consultation. We will help you understand if you are a good candidate for treatment and explain all of our flexible payment options for your consideration.

• 4Will insurance cover treatment in full? 

  Once approved, most state sponsored plans will cover your or your child's treatment in full. If you do have any financial responsibility, it will be outlined on the approval and a Diamond Braces team member will help you understand your responsibility and advise you on flexible payment options. State sponsored insurance will cover in full (metal braces only) or will not cover anything if your case is denied by insurance company.

• 5Will my case be approved?

  State-sponsored orthodontic coverage is subject to a strict set of approval qualifications. If you are an eligible candidate, Diamond Braces will take all the necessary diagnostic records (including x-rays) and send them to your insurance provider for approval. With over 20 years of experience, our orthodontists can generally tell you ahead of time whether you can expect to be approved.

• 6What if my insurance plan changes during treatment?

  If you change to another state-sponsored plan, your coverage generally remains the same and you can expect uninterrupted insurance coverage. If you change to a private insurance plan, your coverage will need to be approved under the guidelines of your new private plan. It is likely that your costs will change given the guidelines of private insurers.  We advise you not to change your plan during orthodontic treatment to avoid interruption in coverage. 

• 7What happens if I lose my insurance during treatment? 

  If you lose your insurance, and/or your new plan no longer covers orthodontic treatment, Diamond Braces will help you establish a flexible monthly payment plan that allows you to pay in manageable installments. Diamond Braces offers customizable options to fit your budget including extended, zero down payment and no interest plans. You will only be responsible for the portion of your treatment that was not covered by insurance.

• 8Does my plan cover Invisalign?

  No. State-sponsored plans cover only standard metal braces. If you prefer Invisalign clear aligners, you may choose to forego using your insurance and instead move forward with a flexible payment arrangement. Feel free to discuss this option during your consultation to decide what is right for you or your child.

• 9Does my plan cover clear braces?

  No. State-sponsored plans cover only standard metal braces. If you prefer clear braces, you may choose to forego using your insurance and instead move forward with a flexible payment arrangement. Feel free to discuss this option during your consultation to decide what is right for you or your child.

• 10Can I upgrade to a cosmetic elective like Invisalign or clear braces and just pay the difference out of pocket?

  No. State-sponsored plans cover only standard metal braces and only when the patient's condition is approved. Your Diamond Braces doctor will be able to explain whether  you may qualify based on your state's guidelines and if not covered, help you decide which appliance is the best choice for you or your child.

• 11Do I need a referral from my primary dentist?

  You do not need a referral from your general dentist. You can schedule a complimentary consultation with Diamond Braces, and our team will take the necessary diagnostic records (including x-rays) to send to your insurance company for review.

• 12Is an approval needed before I start treatment?

  Yes absolutely – a valid approval needs to be obtained from your insurance company before your orthodontist begins treatment. This can take anywhere from one day to several weeks. First you need to schedule an office visit to see your orthodontist. Orthodontist will take necessary records such as X rays, photos. Diamond Braces will submit all required documentation on your behalf.

• 13What if my or my child's treatment is denied?

  If your Diamond Braces doctor observed your or your child's condition to be medically necessary, we may be able to submit an appeal on your behalf. In any situation where an insurance approval cannot be obtained and you wish to move forward with treatment, we will go over all of our flexible payment options and assist you with fitting the treatment cost into your budget in a way that works for you.

• 14Can I get treatment for multiple children?

  Yes. State-sponsored plans treat everyone in your family as an individual policy member. Anyone under 21 whose diagnosis qualifies for treatment coverage can have their costs covered. If one or more of your children is not approved by insurance, you may be eligible for family discounts on our treatment cost, as well as flexible payment options to fit your budget.

• 15Is Diamond Braces in my network?

  Yes. Diamond Braces works with all the major state sponsored insurance plans.