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 or not your benefits include Teledentistry coverage. .
This can all play out a number of ways, depending on your particular insurance provider and plan. It’s possible that your insurance will cover 50% of your SmileDirectClub treatment, plain and simple. It’s also possible that your insurer will deny your benefits even though you actually do 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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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. 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 may also be covered at a lower rate. 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 that 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 braces or Invisalign, and provide coverage accordingly. However, because SmileDirectClub does not involve regular, in-person check-ups, certain insurers incorrectly consider SmileDirectClub “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 stems from online 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 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 or not 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 any number of 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 did respond 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 up front (or sign up for a payment plan) and then receive a reimbursement check from the insurer. Sometimes this reimbursement comes in one lump sum and other times it’s dispersed throughout the 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 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 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.
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 SmileDirectClub’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 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.