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Orthodontic Benefits

Your Direct Dental plan may include coverage for orthodontic services

Not all plans cover orthodontics. Your Plan Benefit Summary describes the services covered by your plan. Your Plan Benefit Summary is available to you in the Member Web Portal or from your HR team.

Covered Orthodontic Procedures

Direct Dental’s allowance for orthodontic procedures includes all appliances, adjustments, insertion, removal and post-treatment stabilization (retention).

Covered Participants and Waiting Period

Please consult your plan benefit summary for participant eligibility for coverage. You may have a waiting period before your Direct Dental Plan will pay for orthodontics.

Orthodontic Lifetime Maximum Benefit

Orthodontic benefits are a lifetime maximum benefit, not annual. Orthodontic benefits through Direct Dental may be used once in a lifetime by each covered participant, including benefits paid by any prior plan offered by your employer. Orthodontic benefits and limits are separate from all other dental benefits under the Direct Dental Plan. Please consult your plan benefit summary for orthodontic benefit coverage amounts.

Orthodontic Treatment Completed Prior to Plan Eligibility

If a patient has completed orthodontic treatment prior to eligibility on the Direct Dental Plan, their treatment is not eligible for coverage.

Orthodontic Treatment In-Progress Upon Plan Eligibility

If a patient is already in treatment upon plan eligibility, and has not paid the entire bill with orthodontist (making monthly payments), then the remaining balance with the orthodontist may be applied against the lifetime maximum. Claims for patients in-treatment upon plan eligibility must include the amount paid prior to eligibility. Keep in mind, enrolling in the Direct Dental Plan does not change the terms of the contract signed with the orthodontist when treatment began. You are still responsible for the orthodontist’s total case fee.

How Orthodontic is Paid by Direct Dental

Your Orthodontic provider needs to submit full treatment details to Direct Dental, including:

  • Initial banding date

  • Initial banding fee amount

  • Approximate treatment time

  • Monthly or quarterly fee amount

Initial banding fees are only paid once by the Direct Dental Plan. After initial banding fees, the provider will bill Direct Dental in monthly installments for ongoing adjustments. Please note that Direct Dental does not automate payments and that orthodontic benefits pay out over the course of treatment and not in one lump sum.

Invisalign® Clear Aligners

Invisalign® aligners are covered under the Direct Dental plan and are paid per the above guidelines.

Dual Coverage & Coordination of Benefits

When Direct Dental is secondary in dual coverage cases, please include the primary coverage’s total liability including copayment/coinsurance percentage and the Explanation of Benefits (EOB).

Questions?

Please contact us at 855-844-0626 or email memberservices@skygenusa.com