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Does CHP Pay for Braces in Colorado?

May 21st, 2020

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!

Does Medicaid Pay For Braces?

May 21st, 2020

This is a question we get nearly every day.  Not only from folks here in Colorado but from around the country.

The short answer: maybe ….

Let us explain.  First, Medicaid coverage for orthodontics varies by state policy.  In some states Medicaid does provide coverage for some cases to be treated, while in others it does not.  Here in Colorado, for example, there is Medicaid coverage for orthodontics. In all states, however, coverage is only for people under the age of 21. If you are 21 or over, have Medicaid, and want braces, we are sad to say that your insurance will not help you with the costs.  You can still get braces, you will just have to pay for them yourself. 

We should note that our practice has a somewhat unique understanding of this topic. A few years ago, in working with our state here in Colorado to design the state criteria, we performed a nation-wide analysis of state-by-state coverage.  Later, as Dr. Baskin, one of our doctors, had been asked to help determine policy for the AAO on medical necessity, we updated this analysis for the AAO. Between these efforts, we came to realize that we might have a stronger grasp on this topic than almost any other practice in the nation.

So let’s say you live in a state that DOES offer orthodontic care and you have a child who you think could benefit from care.  You may ask, how does it work?  Well, to start, we need to provide a bit of “orthodontics 101” education. Orthodontics often has two different phases of treatment. Phase 1 (also called interceptive treatment) is for early care and is done often between the ages of 7-10 while the child’s jaw is still developing and they still have multiple “baby” (also called primary) teeth. This phase typically addresses more structural issues of the jaw such as a narrow palate, impacted teeth or an underbite.  It is done early because a child’s jaw is far more malleable (for example at the top of the mouth, the palate has not yet formed) and so treatment can be done far more easily and quickly than it could in later years, sometime avoiding what would have been surgical solutions later down the road. Phase 2, or comprehensive treatment, is done for people for 10-99.  It’s orthodontic care once most or all of the adult teeth have erupted in the mouth.  It is important to note here that because some children would significantly benefit from early Phase 1 care, our national organization (called the AAO for American Association of Orthodontics) strongly recommends that all children see their orthodontist at age 7.  Not every kid at 7 needs care, in fact most do not, but much like a checkup to the pediatrician, it’s important that children be “checked-out” by an orthodontist when they are 7 or 8.

So, back to Medicaid coverage.  Most, but not all states that provide orthodontic benefits cover both Phase 1 and Phase 2 treatment.  While rules change all the time, to the best of our knowledge there are still some states that do not cover phase 1 care.  For either phase of care, before they will pay for anything, all states require that the need for the child to get braces is “medically necessary”.  How do they determine medical necessity?  Well again this varies by state.  Each has developed its own set of criteria.  Some use one of a few commonly accepted scoring mechanisms.  With these, you get a certain number of points for exhibiting various conditions, and only if your point total meets or exceeds the required amount will the case be considered medically necessary. In other states, like here in Colorado, there is a checklist of criteria.  In theory, if you meet any of the criteria on the checklist, you qualify for coverage.  We say “in theory” because there is still a bit of a subjective element here.  We have submitted cases that we think show 1 or more the criteria and have still had these cases denied for coverage.  Why?  Well, put simply, while our doctors may say that the x-rays and photos of a patient clearly show a condition, the folks who review the cases for the state may disagree.  And in the end, the state reviewers have the final say.

“How often do kids get approved then?” you may ask. As you might imagine, again this varies greatly by state and phase of treatment. Politics and state budgets also sadly come into play. Here in Colorado, for example, as recently as 3 years again, we would often see about half of all kids get approved.  More for Phase 2 than Phase 1, but just over 50% when taken together.  Now, in the past year, that number has dropped to about a third.  As the criteria for Phase 1 is more limited, this splits, roughly, to about 25% of Phase 1 cases being approved and about 40% of Phase 2. If you live outside of Colorado, these numbers could be drastically different.

Medicaid Braces

The last piece to explain here is HOW Medicaid pays. Yet again, it varies by state.  Here in Colorado, they will pay in full for a Phase 1 case.  So, if you had Medicaid coverage on the day your evaluation consultation occurred and continue to have it on the day the braces or appliances are put on, you are all good.  Even if you lose care the next day, the treatment has been paid for.  Years ago, this also was true for Phase 2. But starting in 2017, Colorado changed these rules and now pays the doctor in installments. This can create some financial issues.  If you lose coverage during treatment (Phase 2 often lasts about 2 years), you will most likely be responsible for paying the provider for the remaining care.  What they charge you is completely up to them as, now that Medicaid is out of the picture, the practice can charge whatever they want.  We know many of our competitors, for example, will charge $130-$150 a month for as many months as you still need treatment.  Our practice, knowing the hardship on these families, decided to set a policy of charging $100/month and only charge for the number of months that we did not get Medicaid coverage (so no more than 18 months maximum, depending at what point the patient lost coverage).  If you regain Medicaid coverage at a later date while still in treatment, the practice can attempt to re-apply for benefits and adjust your financials accordingly (you may still owe money for the period where there was no coverage).  And yes, if you get private insurance during this time, this can sometimes be billed as well (depending on the policy).

So what do you do now armed with this knowledge?  Well first, if you have a child over the age of 7 who has not seen an orthodontist (and yes, even if they have seen a dentist, they should be seeing an orthodontist who has 2-3 more years of training specifically on jaw and tooth development and correction), schedule to see one.  It is painless for your child, free to you, and will assure they are getting the proper medical care they need. Secondly, as it relates to Medicaid coverage and approval, work with your orthodontist.  They are on your side and want to get you covered as much as you do.  They can advise if you get denied what the best next step may be (e.g., wait a year and try again, start with mild treatments that do not require approval but are covered by your insurance, etc.). 

Lastly, if you are here in the metro Denver area, we’d LOVE to see you! We openly take all Medicaid 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!

Using a HSA or FSA to Pay for Braces

May 21st, 2020

We know that even though we offer arguably the best value for orthodontic treatment in all of metro Denver, orthodontic care can still be very expensive for most families.  While you want great care for you and/or your child, and so you likely are not just looking for the cheapest provider (as I often note, if you needed open-heart surgery, you wouldn’t look for the cheapest surgeon, but rather a great one that may also be affordable—and we would hope this is the same mindset when looking for an orthodontist in Denver), you still would like to find a place you can afford. With these concerns in mind, we are often asked about financial issues and if we know of any ways to make braces more affordable. To that end, we thought it would be great to discuss the advantages of HSAs and FSAs and how they can save you a significant amount of money when paying for braces.

To understand FSAs and HSAs, we need to begin with a bit of finance 101.  What is an HSA, what is an FSA and how are they different? At a high level, both HSAs and FSAs are ways that the IRS has set up for you to save money on medical expenses. They are similar, but different important ways. So we will now describe each.

Let’s start with FSA. FSA stands for Flexible Savings Account. It is typically offered by large employers and is something that you would ask to have set up during open enrollment for the following year.  The way it works is that you have your employer set aside a certain portion of your paycheck BEFORE ANY TAXES ARE APPLIED to be used for medical expenses. You may then use this money for medical expenses without these funds ever being taxed.  Let’s look at an example. Let’s say you get $1000 of gross pay on your paycheck and you pay 30% in taxes. Normally you’d get a check for $700 after taxes.  Now let’s say you put $100 of what you earned into your FSA account. Your paycheck would now be $900 less $270 in taxes, so $630.  But you also have the $100 you can spend to pay medical bills (typically your employer will provide you with a credit card tied to your FSA account).  As a result, in this example, you end up with $730, or $30 more than if you did not have an FSA. And the FSA funds, as long as they are used for medical expenses, are NEVER taxed. To use these funds, you do need to present evidence to the FSA administrators that the funds were actually used to pay for a medical expense.  In most cases, a simple receipt from the doctor or store (there is a lot of flexibility in what is considered a medical expense, so often things like eyeglasses, over-the-counter medicines, and even things like massages may be acceptable depending on the rules of the plan provided) will suffice. Is there a downside or risk of using an FSA?  Yes. The IRS rules say that if you do not use your FSA funds for the year, whatever balance is remaining gets forfeited to the IRS. Typically (those this does vary by FSA plan) there is a grace period of a couple of months beyond the New Year to spend these funds, but it is important that you plan and monitor this account. The net-net is that FSAs are a great way to save a significant amount in taxes if you have a known medical expense for the coming year (like paying for braces!) but is not something that most advisors would recommend doing if you do not know if you will have any medical expenses of any significance in the year to come. For 2020, employees can contribute up to $2,750 to health FSAs (and yes, spouses can BOTH do this).

An HSA (which stands for Health Savings Account) is similar to an FSA in that it can help pay for medical expenses tax-free, but is different in some key important ways.  Unlike an FSA, you do not need your employer to offer an HSA. Setting up an HSA has two key components.  First, you need to select and HAS-eligible insurance plan.  This will be a high-deductible plan, but the tax savings from the HAS will almost certainly outweigh the added deductible expense you incur. Once you have an HSA eligible plan, you would open up an HSA account. This typically can be done at your local bank. You would then contribute to this account.  While you are obviously funding the account with after-tax money, when you file your taxes the following year you will be able to deduct whatever amount you contributed to your HAS from your taxable income. This will either reduce the amount of taxes you owe or increase your tax refund.  The tax benefit is based on the money you contribute, not on the money you use from this account. One key difference from an FSA is that the IRS will not take this money from you if you don’t use it.  In fact, it can accumulate year-over-year.  Every year, the amount you put in is the amount you will be able to deduct from your taxes when you file. The new HSA limits for 2020 are $3,550 for individuals and $7,100 for families.

Can you have both an FSA and an HSA? Generally speaking, FSAs and HSAs cannot be used at the same time, although a limited-purpose, or "HSA-compatible" FSA, will allow individuals to also receive benefits from an HSA. A limited-purpose FSA is a healthcare spending account that can only be used for eligible vision and dental (and orthodontic!) expenses. So, as it relates to paying for braces, if your employer offers a limited purpose FSA, you can indeed use both.

Another nice element in using these tax-saving tools for paying for braces is that our services are spread out over time.  This offers two main advantages.  First, depending on when during the year you start treatment, you can spread your payments across 2 or even 3 separate years and as such use FSA or HSA funds to pay for the entire cost of treatment—yielding you as much as $1500-$2000 in tax savings.  Additionally, as our services are spread over time, we can, quite legally, adjust the timing of our payment arrangements to better optimize the use of your FSA and HSA accounts. HSA and FSA

We hope that by understanding these tax-saving features it will make it far more affordable to help you and/or your child get the smile of your/their dreams! As always, if you are here in the metro Denver area, we’d LOVE to see you! We openly take nearly ALL insurances, have been named a 5280 Top Orthodontist for the past 10 years, and winner of the #1 practice in the state by Colorado Parent. As noted, we are confident we offer the absolute best value in orthodontics in Colorado, with world-class care at affordable fees. 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!

Will Insurance Help Pay For Braces?

May 21st, 2020

Private insurance can be a very complicated issue, especially as it relates to orthodontic care. In this blog, we’ll try to break it down so that you can best know what your insurance may or may not cover and what to ask when choosing your dental plan at your next open enrollment.

Orthodontics Insurance

First, a bit of a disclaimer that is important to understand when discussing dental insurance. EVERY PLAN IS DIFFERENT.  Even as we discuss generalities of plans below, understand there can and always will be exceptions.  We have seen some crazy stipulations in specific plans and at least once a month, having seen thousands of plans, we still find something that surprises us.  Why are these plans all so different?  Well, put simply, the insurance companies put forth a very wide range of options for your employer to chose from when selecting and forming a plan.  Each of these options has pros and cons.  Some will cost your company more money, but give you better coverage.  Others may save them money, but place greater rules or restrictions on your coverage. Your employer creates the plans with the insurance company in a manner that best represents their desired balance between the coverage they’d like you to have and how much they are will to spend to provide it.

So, do all dental insurance plans cover orthodontics?  No. Some plans do not have any orthodontics benefits.  So while they may help pay to get your teeth cleaned, or a filling at the dentist, they will not cover any of the costs for braces, Invisalign, aligners, or any other type of orthodontic treatment. Other plans that DO have orthodontic benefits may have age limits on these benefits.  For example they may cover your dependants up to a certain age (often this will be something like 19 or 25) but not cover you or your spouse. Additionally, if you get the coverage after braces are already on your (or your child’s) teeth, some plans will cover work in progress while others will not. These are all questions to ask your HR representative before signing up for a plan.

Why don’t all orthodontists and dentists accept every plan? The issue often has to do with contracted fee schedules.  When a doctor agrees to accept specific insurance, they are also agreeing to only charge patients a specific amount dictated by the insurance company. A well known dental plan in this state, for example, has a standard contract across all providers that mandates that their insureds be charged no more than $5,205 for comprehensive orthodontic care or Invisalign.  So, if you are an orthodontist who typically charges $8,000 for these services, you may choose not to join this network as it would force you to take a deep discount on your services.  Alternatively, if you are a doctor that might normally charge $5,300 for these services (or less), you may be excited to join this network as you would be willing to accept the slight discount in return for the increased number of patients who would likely come to see you because you accept their insurance. These negotiated fee schedules can come more into play when it comes to certain discount plans and DHMOs which we will now explain.

Let’s now discuss the two main types of insurance plans: PPOs (Preferred Provider Organizations) and DHMOs (Dental Health Maintenance Organizations). 

  • Typically, PPOs, if they have orthodontic benefits on the plan, will provide specific lifetime coverage for each of the insureds on the plan. These benefits will also have a percentage limit that the plan will plan for the total charges. This is best explained through a few examples. Let’s say (and this is the most typical coverage we see) that your plan provides $1,500 in orthodontic benefits paid at 50%.  If the negotiated fee for braces is $5,200, the plan would pay $1,500 as long as you have the same insurance throughout the complete time of treatment. If, however, the care you are receiving was limited and so you were only charged $2,800, the plan would only pay $1,400 as this would hit the 50% limit set by the plan. Another example, if your child needed early, phase 1 care and you will billed $2,000 for this treatment, the plan would pay $1,000 of the $1,500 benefit.  If years later you still had the same plan and your child needed phase 2 (comprehensive) care, the plan would only pay the remaining $500 of coverage as the plan’s benefits were stipulated as lifetime benefits.  In any of these cases, as is with nearly all dental insurance, the benefits are paid out to the provider over the course of treatment.  So if you lose coverage at any time during care, some of the charges  you may have expected to be covered by insurance will be shifted back onto your account (you can, of course, provide a new insurance and, if it covers work in progress, it can be billed instead).
  • DHMOs can work much like a PPO, or they can work with co-pays associated with each procedure.  If there are co-pays, the provider must calculate your coverage by assessing the difference between the co-pay and the contracted rates for each procedure. Often the number of months your care requires will also drive your coverage as DHMO benefits often involve a monthly care component to this calculation. Again, like a PPO, payments are made over time, so if you lose coverage, you may see charges shifted back to your account.  One of the key benefits, and limitations of a DHMO to you, the insured, have to do with their contracted rates.  Typically, most DMHOs offer greatly reduced contracted fee schedules relative to PPOs.  While this is great for you in you can find an in-network provider that is of high quality (as it forces them to charge you a far lower fee for the service), the issue is that it greatly reduces the number of high-quality providers who are willing to work for these greatly reduced fees.  So yes, you can save a lot of money, but you may have a hard time finding a good and highly reputable doctor who accepts your insurance (they do exist, however—our practice is proof positive of this!). Often there is also the trade-off that while the contracted rates are far more aggressive, the amount paid by the insurance company is often less than the typical PPO plan, so your net out of pocket expense may still be similar.  But again, this can vary greatly and there are exceptions to every point noted here.

Separate from PPOs and DHMOs, there are discount plans.  These plans, if accepted by your provider, will provide you greatly reduced contracted fees, but will not provide any additional benefits beyond these discounted prices.

What if mom and dad both have a child covered under their separate plans? In most cases, the good news is you CAN double-dip and receive benefits from both plans. The way this is calculated become very complex and varies a lot by the plan, but often is based on which plan is considered primary and which secondary.  Believe it or not, the industry has generally used a rule-based on where on the calendar each parent’s birthday falls, with the parent having the earlier birthday considered as having the primary insurance.

So, is private dental insurance complicated? Yes, absolutely! Hopefully, this blog has helped shed a bit more light on dental insurance and how it works. You should also appreciate that the insurance team at your orthodontist’s and dentist’s office are working hard to help you get these benefits. We know we’ll get the same money, in the end, either way, but also appreciate that we have far happier patients that are willing to come back and refer their friends if we can help them get every penny for insurance that is possible. You should appreciate that if you are not getting the coverage you had hoped for or expected, that this is not typically the fault of your doctor’s team, but rather they are on your side to work and communicate with the insurance companies to help you try to receive greater coverage if at all possible.

Lastly, if you are here in the metro Denver area, we’d LOVE to see you! We openly take nearly ALL insurances (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!

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