We see a lot of folks with CHP and CHP+ in our offices. Many have been bounced back and forth between Medicaid and CHP. With many of these folks, there is some confusion on the subject of CHP and how that works with braces. So let us try to clarify.
The answer to the question, “does CHP pay for braces in Colorado?” is maybe and kind of. We know, not much of an answer, so here are the details. The state of Colorado outsourced the processing of CHP to a third party called Dentaquest. This was a relationship that is structured in such a way that Dentaquest acts much like a private insurance company. There are rules and guidelines set by the state which they much follow, but within those rules and guidelines, they get to determine if a claim is approved or denied and it is in their financial best interest to pay out as few claims as they can as long as they remain within the parameters set by the state. The result is, very few claims are approved for CHP.
But what are those guidelines and how do they apply? Well, first, to get coverage, any CHP or CHP+ member must have had CHP for a full year, without a break, at the time of their orthodontic evaluation. Even if you have had CHP for say 18 months, if it was dropped in the middle of those 18 months you are not eligible as it would not have been 1 continuous year. If you meet this criteria, CHP will still not pay for phase 1 orthodontic treatment (for an explanation of phase 1 vs. phase 2 treatment, see our blog “Does Medicaid Pay For Braces?”). If you are looking for phase 2 coverage under CHP AND have had coverage for an entire year, you then would come in for a free consultation and evaluation. During the evaluation, we will score your kiddo against the criteria the state established for medical necessity. This criterion is actually far more limited than the criteria for Medicaid and as such far few kids get approval. In the end, we find that about 10% of kids with CHP get coverage.
What does coverage mean with CHP? Well, sadly, unlike Medicaid, it does not mean that CHP covers the cost for braces. What it means is that the doctor should apply a contracted rate for treatment (at this moment, in early 2020, that’s about $5200) and then CHP will pay $1500 of these charges to the doctor over time. The “over time” piece is important here because if you lose coverage before treatment has continued for at least a year, you will only receive half of this benefit. But, assuming you get the entire benefit, you will still be looking at about $3700 out of pocket. Many providers will do what we do which is to let you finance this interest-free over 2 years, so your payments are likely around $130 per month, but it will still cost you money. In our practice, since we know how unreasonable all of this seems for struggling families with CHP, we offer a substantially discounted rate for care to any of our CHP patients who are denied.
So what does this all mean for you? Well, first of all, if you are one of those families that bounce back and forth between Medicaid and CHP, wait until you are back on Medicaid and then run, don’t walk, to an orthodontist and see if you can get the process all completed before the insurance switches back. Even if you lose Medicaid the day after we started braces, while there will still be out of pocket expenses, in our practice for example, the MOST we would charge you would be $1800 over the next two years. So far, far less than what you would have paid with CHP—and that is a WORST case scenario (it is true that other major practices will charge more than the $1800 noted—this is just our policy for patients who we start with Medicaid and lose coverage. Again, for more on that, see our blog: “Does Medicaid Pay For Braces?”). If you are stuck with CHP and can not get other private insurance and are struggling to pay for braces, look into using an FSA or HAS account to save a ton of money on taxes. Not familiar with these acronyms? Don’t worry, we’ll post another blog about these very soon.
Lastly, if you are here in the metro Denver area, we’d LOVE to see you! We openly take all CHP and CHP+ patients (and to our knowledge are the only 5280 Top Orthodontist (and have been for 10 years!) and winner of the #1 practice in the state by Colorado Parent magazine that does so), and, while still a family-owned and operated practice, have 9 locations throughout the city to see patients. Just give one of our offices a call and schedule for a consultation.
We hope this all helps!