Aetna Dental is one of the major dental insurance carriers in the US and they do in fact cover Invisalign and orthodontic treatment. This is a guide giving a real example of Invisalign coverage by Aetna Dental to prove that they do cover it and what your out of pocket cost could potentially be.
Table of Contents:
Does Aetna Dental cover Invisalign?
Aetna Dental does cover Invisalign but it all depends on if orthodontic benefits are included in the contract of your insurance plan. You must read the fine print in the insurance contract to make sure that orthodontics and Invisalign are an included benefit. As long as it says that it is a provided benefit, you will most likely have coverage for not only Invisalign but other orthodontic treatment as well.
What to watch out for:
There are a couple of clauses in the insurance contract which you should pay close attention to because they may potentially deny you coverage for Invisalign. These are the clauses that you should look for:
Non-covered service. If there is a clause that says orthodontics is a non-covered service or a non-covered expense, you will not have any coverage for Invisalign.
Limitations and exclusions. There may be a clause where Aetna says that there are orthodontic benefits but it is only for those age 19 or under. This is a limitation and it excludes all insured members under the plan over the age of 19 from receiving orthodontic benefits. Yes, the plan does have an Invisalign benefit but only if you are within the age limitation.
To ensure that your insurance plan has coverage for Invisalign, make sure you choose a plan that does NOT have the above two clauses. You must read the contract carefully and pay attention to any exclusions or limitations.
Network status of your dentist or orthodontist
Aetna Dental can provide coverage for orthodontics regardless of the status of the dentist or orthodontist. This means that it does not matter if your provider is "in network" or "out of network".
The only instance it would make a difference is if there is a clause in the contract, which states "In Network Only". If you have that clause then you must see a provider who is in network because an out of network provider would be a reason for your insurance to deny the claim. That is another exclusion to look out for!
Coverage for other types of aligners?
Aetna Dental typically does not make a distinction among the different types of invisible aligners so when they cover Invisalign, they will cover the other types of aligners as well. This is a list of some of the most popular clear aligner systems that are being used in the United States. It is not meant to be comprehensive but just to give you an example.
Coverage for DIY aligners
Aetna does cover DIY aligners, in fact they have a partnership with SmileDirectClub through CVS. You will be considered in network if you have Aetna and you get SmileDirectClub.
Here is a list of some DIY aligners, which is not all inclusive since there are new companies coming onto the market continuously:
Coverage for braces?
Aetna Dental will cover traditional orthodontics because most of the pre-determination claims that we receive back from them do not specifically mention braces or Invisalign. The pre-approvals only say "approved orthodontic treatment" without mentioning what type of orthodontic treatment. Therefore the short answer is yes, braces are a covered treatment.
Average cost of orthodontics before insurance
The average cost of Invisalign will be between $4000-$8000 but it depends on the cost of living of where your dentist is located. If you go to a dentist in a low cost of living neighborhood, it would be on the lower end averaging between $4000-$6000. If you see a dentist in a high cost of living area, it would be on the higher end, costing between $6000-$8000.
Of course, these are the fees without any insurance coverage but if you do have coverage for orthodontic treatment, it will bring the out of pocket cost down.
Example of a real Aetna Dental Invisalign claim
This is a real Aetna Dental Invisalign insurance claim but with the confidential information blocked out. It will provide enough information for you to understand what the coverage is going to be.
For this claim Aetna Dental will cover 50% of orthodontic treatment BUT it is not that simple.
The insurance actually has a ceiling limit or cap on the maximum amount that they would cover and that would be $5291 and they would cover 50% of that. This means that your insurance would provide a benefit of $5291 x 50% = $2645.50 but since they have a maximum benefit of $2500, it won't fully cover that.
$2500 is what your insurance would contribute to the treatment since that is the MAXIMUM benefit.
In this case your out of pocket cost would be the difference of $5291 - $2500 = $2791
However you should be aware that there may be additional fees that are not included such as the permanent retainers at the end of treatment. There may be consultation, x-rays, exam, and other procedures which are not included. These all increase the total out of pocket cost.
Exceptions: There is one additional thing that you should watch out for and that is an orthodontic benefit maximum. It seems like this particular plan has a $2500 benefit maximum and that is what they will contribute.
Your plan may have a lower maximum which can be $1000. If you only have $1000 the calculations would be as such $5291 x 50% = $2645.50. That would be what they would consider but since you only have a $1000 benefit maximum, it would only contribute $1000 towards your total treatment
Your total out of pocket cost would be $5291 - $1000 = $4291
Hopefully those calculations make sense!
How to choose the best Aetna Dental Plan for orthodontic coverage
Every insurance plan under Aetna is different because they all come with different benefit amounts and different exclusion criteria. These benefit amounts and exclusion criterias are all determined by your HR which negotiates with the insurance carrier. In order to position yourself for the maximum amount of orthodontic coverage, here are some fine print that you should look for:
Choose a plan that HAS orthodontic benefits.
Pick the plan with the highest orthodontic coverage %
Make sure that there is no exclusion criteria such as an age limitation on the benefit. An example would be orthodontic benefits only for those under age 26 or age 19.
Choose a plan that has a high maximum for orthodontics. For example if there was a plan that offered $1000 benefit vs a $2000 benefit, you should choose the $2000 one.
As long as you follow the above guidelines, you should be able to decrease your out of pocket expense by maximizing your insurance coverage.
How to file a claim
Most dental offices will film the insurance claims on your behalf so you don't have to submit any paperwork on your own. In fact when you first filled out all of your check-in forms on your first visit, all of that information you entered was so that your dentist can submit the claim on your behalf. You don't have to sign anything either, your dentist will file everything electronically. However, if you did not give all of your information, you would be responsible for filing your own claims.
There is an exception and that is some dental offices may not submit the claim on your behalf. If this is the case, you would have to fill out the claim yourself and submit for reimbursement. You can find a copy of the American Dental Association dental claim form here.
Dental Code to use for submitting for Invisalign
The ADA insurance code that you should use to submit for all orthodontic treatment, whether it be braces or Invisalign is D8090. That code is all inclusive for moving your teeth. There is no additional code that you need to submit.
Alternative payment options
Most dental offices will offer multiple payment options for Invisalign in order to help you get the treatment that you want. There are multiple financing options but they all require a credit check, which typically uses your driver's license number as verification. This means that if you have good credit, you will most likely get approved but if you do not, then you won't get approved.
Here is a list of some common dental financing options:
Most of these financing options offer long term repayments with an interest rate of ZERO. This means that whatever the cost of treatment is, will be exactly what you will pay. You won't have to pay additional monies for the interest to be on these payment plans. It is a very good offer and if you are able to take advantage of it, you should do it!
Alternatively you can always pay with cash, check, or credit card.
VISA
Mastercard
Amex
Debit
All dental offices will also accept HSA (health savings account) and FSA (flex spending accounts) cards, which work similar to a debit card. Most employers will approve all expenses at a dental office and that includes Invisalign. We have not seen any claims get rejected for orthodontic treatment yet. Sometimes they may ask for additional information but it usually gets approved by HR.
There is a possibility that some dental offices may accept cryptocurrency but ours do not.
Takeaway
If you were still wondering if Aetna covers Invisalign, the short answer is YES. However, that depends on the insurance plan that you chose and whether or not it has orthodontic coverage. If it does then you can expect to pay less out of pocket. If it does not then you'll have to pay the full price.
The amount of insurance contribution and coverage will depend on the specifics within your plan. That is why it is important to read the fine print closely to make sure that you are eligible under the plan rules.
Author: Written by Dr David Chen, a cosmetic dentist in long island city.
