Your dental insurance covered your last cleaning and the filling before that. You might’ve even used it for a root canal last year. So it should cover your teeth straightening treatment too, right? Not always. Getting coverage for your orthodontic treatment depends on a few different factors, primarily whether or not your benefits include Teledentistry coverage.
We’ll start with the good news: depending on your specific insurance plan, you might receive coverage for a portion of Candid’s price. But there’s also a chance that your insurer will deny your claim (even if you have orthodontic benefits). How can you find out? Read this guide. It will explain the policies and procedures involved with benefit claims for Candid’s at-home orthodontic treatment.
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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 Candid. 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. They’re considered a cosmetic treatment, not medically-necessary, so if you just have standard health insurance, you’ll be stuck with the full bill.
What If I Have Dental Insurance?
Dental insurance can be paired with standard health insurance to cover preventative care (like semiannual cleanings) and other routine procedures (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 for 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 be aware of the distinction between “in-network” and “out-of-network” coverage. Treatment by out-of-network providers can be subject to higher deductibles, and less coverage. Home-based treatment options, when covered, are teledentistry services that are usually considered out-of-network. Candid currently partners with Anthem Blue Cross, Anthem BlueCross BlueShield, Empire BlueCross, Empire BlueCross BlueShield, and Aetna as an in-network orthodontic service.
The moral of the story is that you shouldn’t simply assume that your dental insurance will cover Candid — or any orthodontic treatment, for that matter. But you should still familiarize yourself with your plan’s details and contact your provider to see if you’re eligible for coverage.
Is Candid Covered Differently Than Braces or Invisalign?
Next scenario: you have dental insurance and orthodontic benefits. Will you receive coverage for Candid treatment? Surprisingly, not always.
Candid ensures that your treatment will be designed and monitored by a licensed orthodontist in your state, but the entire process is remote. Some dental insurers treat Candid just like braces or Invisalign and provide coverage accordingly. However, because Candid does not involve regular, in-person check-ups, certain insurers incorrectly consider Candid “do-it-yourself” treatment and routinely decline to provide coverage.
It’s important to draw a distinction between home aligners and the recent concerning trend of DIY orthodontics. The latter gained popularity because of videos where people attempt to shift their own teeth using rubber bands and other crude materials, and it can be highly detrimental to your teeth. At-home treatment through a provider like Candid 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? While various companies might provide reimbursement for remote treatment (depending on your plan), Candid only has a few partnerships with a solid track record of approving coverage:
- Anthem (which includes Anthem Blue Cross and Anthem BlueCross BlueShield)
- Empire (which includes Empire Blue Cross and Empire BlueCross BlueShield)
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?
First, you should check with your provider to confirm that you have orthodontic benefits. Specifically, Candid says you should ask if you’ll receive coverage for “remote treatments billed with the code D8040.” Unlike other at-home aligner companies, Candid will not do this preliminary check for you.
If your insurance provider confirms that you’re eligible, great! Keep in mind, though, that being eligible doesn’t guarantee you’ll receive coverage. You’ll need to file a claim to find out for sure. Some customers have said that initially, their insurance company said they’d partially cover code D8040 remote treatments, but then denied the actual claim. Just like other medical or dental insurance claim processes, the insurer can initially deny the claim for any number of reasons, often ones with easy remedies. Candid will help navigate a dispute, but only if it was because of an error on their end.
How Do I Claim My Insurance Benefits?
Filing a claim requires a Candid account and treatment plan. To get one, start the treatment process by purchasing and completing a Starter Kit or visiting a Candid Studio. Then, you’ll get an email from Candid that lets you log in to your account. You’ll need to be assigned an overseeing orthodontist before continuing.
Once you have your treatment plan and assigned orthodontist, it’s claim time. Sign in and select the “Account” tab in the top right. Click the link that says “My Insurance.” This page contains instructions for checking with your insurer and filing a claim. Fortunately, you won’t have to handle the paperwork. Just enter your insurance information and Candid will do it for you. After this step, you’ll have to handle all correspondence with your insurance company.
If you have insurance through Anthem (or one of its subsidiaries), you’ll be in-network and Candid can deduct the coverage amount (often around $1,000) from your initial price. If you’re out-of-network but still receive coverage, it will come in the form of a reimbursement check. So, you’ll have to pay upfront or jump on a payment plan, then wait for payment from your insurer. Sometimes this reimbursement is one lump sum and other times it’s spread throughout your treatment.
What If My Insurance Company Denies My Benefits?
Again, just because an insurer covers treatments coded with D8040 doesn’t mean that they’ll approve your claim. In online reviews, some customers have been told by their insurance companies that they’ll receive coverage, then had their claims denied. And Candid will only help in certain cases.
It all depends on why the company denied your claim. If it was because of an error on their end in completing and submitting the paperwork, they’ll rectify it as soon as possible. However, if it was any other reason, you’ll need to discuss it with your insurer directly.
Sometimes it’s just a matter of defining the treatment properly with an agent. At-home aligners are a new treatment and just starting to be covered by insurance, so the agent might be unfamiliar with them.
But other times, it’s because they simply don’t cover remote treatments. In these cases, you can potentially appeal the insurer’s decision. According to Healthcare.gov, you have the right to 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 Candid doesn’t help with the process.
You can also look into financing and payment plans to help make the treatment price more manageable. Candid offers a plan where you’d pay $199 down, then $65 per month for 36 months. This plan requires a credit check, but nearly everyone qualifies.
Candid also offers financing through a third-party company called Affirm. This plan has a more selective credit check, but doesn’t require a down payment and has 0% APR.
If you believe you’re eligible for orthodontic coverage, but feel overwhelmed by the process of claiming benefits, you may wish to consider one of Candid’s competitors – Byte. In our opinion, Byte has the most supportive, knowledgeable, and genuinely helpful insurance experts in the industry. Plus, they handle all of the paperwork for you!
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 higher-deductible plan, though), and they’re also a viable payment option for your Candid treatment.
Whether or not you’re covered by your insurer, Candid will let you pay for their treatment using an HSA or FSA account. If your account is linked to a debit card, just use it like you would any other card. Otherwise, reach out to a Candid representative 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!
If you’re considering Candid treatment, don’t rule out insurance coverage! Customers receive reimbursements more often than you might think. While Candid doesn’t have as many in-network partnerships as some competitors, you can still significantly reduce your treatment expenses.
Of course, it all depends on your specific provider and plan, so check with the insurance company before you do anything else. Once you’ve got that squared away, you’ll have a better sense of your total Candid price and one step closer to beginning your smile journey.