You know the drill: present your insurance card, pay your copay, and go about your day. It’s how we handle most of our medical transactions. But orthodontic treatment — especially remote options — is a different ball game. Getting coverage for your SmileDirectClub treatment depends on a few different factors, primarily whether your benefits include teledentistry coverage.
This can play out in 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.
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SmileDirectClub Insurance Coverage: The Basics
In the dental insurance world, at-home aligners are a complicated subject. Some companies treat it as a cosmetic procedure and refuse coverage, while others are more open to it. Fortunately, SmileDirectClub partners with a few big-name insurance companies. These are the ones with a good track record of supporting them:
- Anthem Blue Cross
- Capital Blue Cross
- Empire Blue Cross Blue Shield
- Dominion National
If you have a plan with one of these companies, it doesn’t mean you’re automatically covered, but the chances are better. And even if your provider isn’t listed here, your treatment might be covered. Keep in mind that this is a rapidly changing situation. Insurers are constantly reviewing treatment options and changing their policies based on new research and data.
Does Health Insurance Cover Orthodontics?
The answer to this question is simple: no, health insurance doesn’t cover orthodontics. And it doesn’t matter if you are looking at a traditional option like braces or a remote one, like SmileDirectClub; health insurance excludes dental coverage, and orthodontics falls under that umbrella. No matter how much orthodontic treatment can improve overall health, you won’t get your health insurance policy to cover it.
And if these policies don’t cover traditional orthodontics or preventative dentistry, they won’t pay for remote aligners, which most dental policies classify as cosmetic treatment. So if you have health insurance without a dental policy, expect to pay for your SmileDirectClub treatment in full.
What If I Have Dental Insurance?
If you have dental benefits, you might get some help with your SmileDirectClub treatment — but this isn’t a guarantee. Dental insurance typically covers preventative care (like semi-annual cleanings) and other routine procedures, such as fillings, root canals, etc. Orthodontic treatment requires special coverage that isn’t built into every dental plan. Even when it is, it comes with special considerations.
- Lifetime Coverage Limits: Most policies with orthodontics coverage have a lifetime limit, either per policy or per person. Once you hit that limit, you’re left to pay for treatment on your own. In many cases, this limit is low enough that even when you max out your benefits, you’ll still pay some costs out of pocket.
- Percentage Covered: In many cases, dental policies won’t pay in full for orthodontic treatment, no matter your lifetime or annual limit and whether you’ve reached it. Instead, they pay for a specific percentage — usually 50% or less. And coverage gets cut off when you hit that percentage or your limit, whichever comes first.
- Waiting Periods: Many dental policies have a waiting period after enrolling in a plan, meaning you cannot use your benefits until a certain amount of time has elapsed. Typically, the waiting periods are 3–6 months for basic procedures and 6–12 months for major ones. Orthodontic treatment tends to fall into the latter category.
- Age Restrictions: Even if your dental policy includes orthodontic coverage, it might exclude anyone over 19. Since orthodontic treatment is easiest — and thus cheapest — for those with bone growth left to come, insurance companies prefer to stick to covering treatment in children and teens.
To summarize, even if you have dental coverage with orthodontic benefits, don’t assume it will cover SmileDirectClub, or any other orthodontic treatment, for that matter.
Is SmileDirectClub Covered Differently Than Braces or Invisalign?
Next scenario: You have dental insurance and orthodontic coverage and there are no restrictions stopping you from utilizing your teeth straightening benefits. Will you receive coverage for SmileDirectClub treatment? Surprisingly, not always.
SmileDirectClub treatment plans are approved by licensed dentists and orthodontists, and their team supervises your care remotely. Thanks to the involvement of licensed professionals and oversight, some insurance companies treat SmileDirectClub the same as braces or Invisalign, offering identical levels of coverage. Others reduce coverage or exclude it because it can only treat cosmetic issues.
Then there is the issue of in-network vs. out-of-network providers. You can work with either, but out-of-network providers usually receive less coverage and have higher deductibles. Teledentistry providers are typically classified as out-of-network, and this includes SmileDirectClub.
Finally, some insurance providers simply see at-home aligners as illegitimate orthodontic treatment. While this is changing, the industry is still new enough that some companies remain skeptical of covering at-home treatments over braces or Invisalign.
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 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 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 FAQ page, “in most cases, SmileDirectClub will coordinate payment directly with the insurance company, so you only pay the balance of what you owe after insurance coverage is applied to your total treatment cost.” 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 Claim?
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 still 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. They also work with a third-party financing company, but be sure to do your research and read the fine print, since third-party options usually include interest and can cost you more in the long run.
What About HSAs and FSAs?
Whether or not your insurance will step in to help pay for SmileDirectClub, if you have a Flexible Spending Account (FSA) or Health Savings Account (HSA), you might be able to use the funds to cover treatment costs. These accounts allow you to save pre-tax income and use those funds for medical expenses.
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 want to use your FSA funds, remember that they expire each year — they don’t roll over like they do with an HSA. Be sure to time the start of your SmileDirectClub treatment to use your money before it’s gone.
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.
Frequently Asked Questions
Do all insurance companies cover at-home aligners?
No, there are still quite a few dental insurance providers that are resistant to covering remote aligners and teledentistry at large. This is evolving, and more and more companies open up coverage each year. However, there is still enough suspicion around mail-order aligners that they’re harder to get coverage for than traditional orthodontics.
Why are some insurers hesitant to cover online aligners?
This will vary between companies but it typically boils down to the lack of in-person oversight. When you aren’t seen in person, certain rare complications can be missed. Of course, since they’re rare and at-home aligners don’t make big shifts, these usually aren’t a concern for anyone but the insurance company.
Which insurance companies are known to work with SmileDirectClub?
SmileDirectClub treatment is often — though not always — covered by the following companies:
- Blue Cross Blue Shield
- Dominion National
How do I find out if my company offers coverage?
You can ask SmileDirectClub to contact them for you or reach out on your own. Since you will need to handle at least part of the process yourself, reaching out on your own may be the most logical choice.
What should I do if my insurer doesn’t cover remote aligners?
Start by making sure they exclude all remote aligner treatments; sometimes, they will extend coverage to limited companies. If they don’t pay for any remote aligner companies, ask about traditional aligners and coverage limits. After this, see a dentist or two to get quotes for treatment. See how this cost after insurance compared with just paying for remote aligners, either outright or with financing.
How long have at-home aligners existed?
SmileDirectClub is actually the oldest at-home aligner company. They launched in 2014, essentially creating the industry.
Are at-home aligners safe?
At-home clear aligner treatment plans are always designed and/or approved by a licensed dentist or orthodontist — as long as you’re buying from a legitimate clear aligner service.
The main concern regarding the safety of fully-remote clear aligner treatment is the lack of face-to-face care. Since you won’t be seeing a dentist in-person during treatment, you won’t receive the same level of support that you’d get with traditional in-office aligners like Invisalign or ClearCorrect. That said, a recent NIH-funded survey found the majority of at-home aligner customers were satisfied with their results, and only 6.6% experienced side effects necessitating a visit to their local dentist.
Read our guide to safe home teeth straightening treatment for more information.
Are there other options that might be covered?
If your insurance provider does not extend coverage to at-home aligners, you can look into traditional orthodontics, like braces and in-office aligners. Assuming you have orthodontic benefits and aren’t excluded due to age or having used your yearly or lifetime benefits, your provider will likely offer some level of coverage.
What are reasons adults can be denied orthodontic coverage?
The number-one reason is age. Many policies only cover orthodontic treatment if the patient is 19 or younger. You can also be excluded if your misalignment is strictly cosmetic in nature or if you have used your full benefits already.