Frequently Asked Questions

General FAQs - Employers & Groups

Orthodontic FAQs - Employers & Groups

  • How are orthodontic benefits paid?

    Orthodontic benefits are paid over the course of treatment. An initial payment is made when treatment begins, and the remaining eligible benefit is distributed throughout the treatment period based on the member's plan benefits and orthodontic maximum. The method used to calculate the initial payment and subsequent monthly payments has recently been updated. The initial amount considered for payment is now based on the total treatment fee, rather than a percentage of the total treatment fee. Here’s an example of how orthodontic services will be paid moving forward.

    Calculation How is it Calculated? Example
    Start with the total fee for treatment. Total orthodontic treatment fee submitted with the claim. $5,000
    The amount considered for the initial payment is determined by the total treatment cost. Because the total case fee is greater than $5,000, the initial amount considered is $1,000. If the total treatment fee is less than $1,000, $500 is considered. If the total treatment fee is $1,000 or greater, $1,000 is considered. $1,000
    Calculate the initial benefit payment based on the member's 50% coinsurance to get the initial payment from Delta Dental. Initial amount considered x applicable coinsurance/copay $1,000 x 50% = $500
    The initial payment is subtracted from the lifetime plan maximum to determine the remaining eligible benefit, which will be distributed across the remaining treatment months.  Lifetime maximum - initial payment = remaining eligible benefit $2,000 - $500 = $1,500
    Monthly payment considered is determined by dividing the remaining benefit (from the previous step) by the amount of remaining months of treatment. The initial payment is the total for the first month of treatment, so in this case there are 23 months left. Remaining eligible benefit + remaining monthly payments = monthly payment amount $1,500 ÷ 23 = $65.22

  • How will the recent calculation change impact members currently receiving orthodontic treatment?

    Members who are already in active orthodontic treatment may see changes to future monthly payments because their remaining benefits will be recalculated under the updated methodology. View our Delta Dental of Illinois orthodontia payment and takeover policy and procedures for more information. 

  • How is the initial orthodontic payment determined?

    The initial payment is based on the total treatment fee submitted by the orthodontist. A fixed amount is used to calculate the initial benefit, and the remaining eligible orthodontic benefit is then distributed over the rest of the treatment period.

    To determine the initial payment, a fixed amount will be applied based on the total treatment fee submitted with the claim.

    • For orthodontic treatment with a total treatment fee less than $1,000: $500 will be considered at the applicable coinsurance/copay.
    • For orthodontic treatment with a total treatment fee of $1,000 or greater: $1,000 will be considered at the applicable coinsurance/copay.

    For example, a member receives orthodontic treatment with a total treatment fee of $5,000 and has a plan that pays 50% of covered orthodontic services. Because the total treatment fee is greater than $1,000, the initial payment is based on $1,000.

    • Initial amount considered: $1,000
    • Plan pays 50%: $500 initial payment

    The remaining eligible orthodontic benefit is then distributed across the remaining treatment months according to the member's plan benefits and orthodontic maximums.

  • How are monthly orthodontic payments determined?

    After the initial payment is made, the remaining eligible benefit is divided over the remaining months of treatment. Monthly payments are based on the plan's orthodontic coverage, remaining orthodontic maximum and treatment duration.

  • Will the recent orthodontic benefit calculation change affect the total orthodontic benefit available to members?

    No. The change only affects how payments are distributed over the treatment period. Total orthodontic benefits remain subject to the member's plan provisions and available orthodontic maximum.