How Will My Orthodontia Claim Be Paid?
A common feature of orthodontics is payment in advance for a period of treatment that lasts 24 or more months. Because you can be reimbursed only for expenses incurred during the plan year, the expense will be divided over the period during which services are rendered. The claims adjustor will usually follow the payment set up by the orthodontist. You can be reimbursed up to 30% of the total orthodontia fee for the cost of initial services.
As an example, 25% of the total orthodontia fee might be allocated towards offsetting the cost of spacers, banding, etc. You will be reimbursed this 25% soon after the treatment begins. The remaining 75% will be divided by the number of months of treatment. A fee of $2,400 for treatment lasting 24 months would be reimbursed in one payment of $600 (25% of $2,400) and payments of $75 each month for 24 months. See Example 1 below.
If the treatment has already begun and you have not been reimbursed pre-tax for the cost of initial services, the total orthodontia fee will be divided by the number of months of treatment. The result is the amount payable during any month of the plan year in which treatment is provided. For example, in a full plan year, a fee of $2,400 for treatment lasting 24 months could be reimbursed at the rate of $100 per month. See Example 2 on the reverse page.
| Example 1: TREATMENT THAT WILL BEGIN IN THE UPCOMING PLAN YEAR |
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EXAMPLE |
Your Information |
For how many months will I receive reimbursement checks?
You may be reimbursed only services that are provided during the plan year. If the treatment period is longer than 12 months, you will most likely be reimbursed for the expenses over two or more plan years. In Example 1, the employee will be reimbursed $75.00 each month for the next 24 months, beginning with January 2010. Treatment ends on December 31, 2011 and no further reimbursements can be made.
Example 2: TREATMENT THAT HAS ALREADY BEGUN
Plan year begins January 1, 2010 |
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EXAMPLE |
Your Information |
For how many months will I receive reimbursement checks?
You may be reimbursed only for services that are provided during the plan year. If the treatment has already begun, you can only be reimbursed for services that will be provided in the future (for example, monthly visits). If treatment is scheduled to extend beyond the end of your plan year, you will likely be reimbursed for the expenses over two or more plan years if you elect to participate in both plan years. In Example 2, the employee will be reimbursed $100.00 each month for the next 12 months, beginning with January 2010. (Twelve months are used because there are 12 months of treatment still remaining on January 1, 2010.) Treatment ends on December 31, 2010 and no further reimbursements can be made.
Claims Submission
To receive reimbursement, submit a completed claim form to Benefit Administration Company. Attach either the contract or a letter from your orthodontist. Be sure the documentation has the total cost, amount paid by any other plan, estimated number of months of treatment, the date treatment begins and the amount of the down payment. You are required to submit only one claim form per plan year for orthodontia. Reimbursement will be made automatically after your first contribution of each month.
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