How does the new Insurance Law affect Braces?

 Steiner  Ranch  Orthodontics

James R. Waters, DDS, MSD, PA

Board Certified Treatment for Children, Teens and Adults  

How does the new Insurance Law affect Braces?

Over the last year, there have been significant changes to the American insurance system.  I myself was kicked off a plan, chose another for my family and now that plan is being cancelled and the provider has informed my they will only offer HMO plans.  But how does this affect your coverage for braces?

Generally, plans on the Obama care exchange will tell you they cover “orthodontics for everyone” (even my carrier told me this was a great selling point I should spread for them) however the fine print tells the real truth.  Coverage is only for “Medically necessary” procedures.  To this, the carriers provide a lengthy questionnaire making it impossible to receive coverage unless there is a facial deformity or rare genetic syndrome (that is not normally seen in private practice in the first place).  I have scored terrible malocclusions with underbites and asymmetries to crossbites and missing teeth and not once have I even been close to reaching their threshold for coverage.

Regular dental insurance provided by your employer or purchased separately remains relatively unchanged.  You may have a “preferred provider” but in truth, the limit for coverage is always less than the fee (usually you get $1000 to $2000 dollars), so it is rare that you cannot see the orthodontist of your choosing.  I am not a preferred provider for any one plan but I accept every insurance.  In almost every case, the patient gets exactly the same cost with me versus another “preferred provider”.  Why is this?  Let me explain a preferred plan.

So every few months I get a call or an email from a provider, the last one was Blue Cross/Blue Shield so I will use their letter to illustrate.  The representative sends me a letter and states that they have many patients they can send me and that I already treat a fair amount of their clients.  The told me how great my reviews were with the patients and how they really want a Board Certified provider of my caliber and experience as a preferred provider for their clients.  They ask me to join by simply filling out some paperwork. 

Who wouldn’t join to such a caring and clearly enlightened group?  So I send an email to request the paperwork, excited to be held in such high regard and flattery.  The response?  A simple email stating they will add me to their preferred provider list if I just agree to drop whatever my regular fee is by 20%.  No paperwork, no rigid proof of my credentials, no case reviews.  Simply reduce my regular fee 20%.

So remembering that braces cost from $5500 to $6000, I realize they are asking me to either raise my fee to cover the “plan” or lose over $1000 per case.  Keep in mind that overhead runs about 70% in a modern dental practice.  Losing $1000 to $1200 per case would simply remove nearly all of the profit margin. 

So how do doctors do it?  Well there only a few scenarios it will make sense; they are employees of a larger business model or company (and will have no ownership or responsibility to the patient), they might be starting a new practice and want to build up patients (or they are selling a practice and want to build up more of a patient pool), or they are raising their fee to an imaginary number taking into account the 20% hit they are taking.  And what about the patients?  What do they get?  No real coverage, just a list of orthodontists (sometimes even un-trained non-accredited general dentists) that at best may not have the patient’s treatment as their only concern.  They may cut out better wires, reduce some of the appliances to reduce lab costs, take braces off a little early or stop taking the insurance mid-stream.

So personally I prefer to be upfront with all patients equally, whether they are paying out of pocket or they have great insurance; whether they are wealthy fund managers or house cleaners.  Price at my office is based on individual treatment needs only and I use the best appliances for each patient accordingly (and I sell it this way); I have found that my fees mirror closely fees of most providers which tells me there is some slide of hand when offering “discounted plans”.  Just keep in mind that if you have dental insurance it will most likely cover you the same with all orthodontists.  And if it seems too good, remember we all run with similar expenses; what are the chances someone will treat for $1200 less than the average fee?  In this day, it pays to be cautious with insurance companies and their promises.      

If you have questions or comments concerning this or any orthodontic question, please feel free to make a complimentary new-patient appointment at either my Steiner Ranch location or my North-central Austin location on West 35^th Street and MoPac.

Dr. James R. Waters is a 1996 graduate from UTHSC Dental School in San Antonio, 1997 graduate of Advanced Dentistry from the UNMC in Nebraska and the 2001 Valedictorian graduate from the prestigious Saint Louis University Orthodontic Program receiving the J.P. Marshall award for clinical excellence in 2001.  He holds a Bachelor’s Degree in Science, Doctorate in Dental Surgery, a post-doctorate certificate in Advanced Dentistry, post-doctorate Degree in Orthodontics & Dentofacial Orthopedics and a Master of Science Degree in Orthodontics.  Dr. Waters and his wife of 19 years live in Austin, TX with their 4 children where he has a thriving, multi-faceted Specialist practice with locations in Steiner Ranch and North-Central Austin.  You can learn more about Dr. Waters at BracesAustin.com. 

Central Austin

1814 W. 35^th Street

Austin, TX 78703

(512) 451-6457

Steiner Ranch

4302 N. Quinlan Park

Austin, TX 78732

(512) 266-8585

Bracesaustin.com