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Orthodontic care FAQs for individuals and families


Orthodontic care

No. You do not need a referral for orthodontic treatment. If you are an Aetna DMO®plan* member, however, you must see an orthodontist who participates in our network.

 

* Illinois members: State laws vary with regard to out-of-network benefits. In Illinois, DMO plans provide limited out-of-network benefits. However, in order to receive maximum benefits, members must select and have care coordinated by a participating primary care dentist. Illinois DMO is not an HMO.
Virginia Members: In Virginia, DMO is called DNO (Dental Network Only). DNO (Dental Network Only) in Virginia is not an HMO. To receive maximum benefits, members must choose a participating primary care dentist to coordinate their care with in-network providers.

Not all dental benefits and dental insurance plans include orthodontic coverage. Please see your plan documents for coverage details.  You may also call Member Services at the number on your ID card.

It depends upon your specific plan. Some plans have a work-in-progress exclusion. That means the plan will not cover treatment that started when you were covered by another plan.

If your plan does not have a work-in-progress exclusion, we determine your coverage based upon:

  • What is covered by your Aetna dental plan
  • Your current treatment stage
  • How much your prior dental plan has paid so far

No.

If you are an Aetna DMO member, coverage will be determined at the DMO in-network benefit level.

Send us:

  • A pre-treatment estimate from your prior dental plan
  • A claim form with your prior plan's:

    • Explanation of Benefits notice
    • Deductible and copay/coinsurance amounts
    • Maximum coverage amount and the amount your prior plan has paid to date

When we receive your information, we will send you coverage details specific to your plan.

Freedom of Choice dental plan members can switch between an Aetna DMO® plan* or an alternate plan (either PPO, PDN** or Indemnity plan) on a monthly basis. Here's how orthodontic coverage works:

 

Switching from DMO to PPO/PDN or Indemnity plan
 

  • Benefits are subject to the new plan's orthodontic maximum
  • If the new plan doesn't cover orthodontia, no benefits can be paid
  • If you switch back to the DMO plan, the months you were covered under the Indemnity or PPO/PDN plan will be deducted. That means no benefit is paid for that time period.

Switching from PPO/PDN or Indemnity to a DMO plan

 

  • DMO plan benefits are not subject to the Indemnity or PPO/PDN plan maximum. DMO plan orthodontic benefits are based on a 24-month lifetime plan maximum.
  • When you switch to a DMO plan, benefits for any remaining orthodontic treatment will be considered as one course of treatment limited to 24 months.

 

* Illinois members: State laws vary with regard to out-of-network benefits. In Illinois, DMO plans provide limited out-of-network benefits. However, in order to receive maximum benefits, members must select and have care coordinated by a participating primary care dentist. Illinois DMO is not an HMO.
Virginia Members: In Virginia, DMO is called DNO (Dental Network Only). DNO (Dental Network Only) in Virginia is not an HMO. To receive maximum benefits, members must choose a participating primary care dentist to coordinate their care with in-network providers.

 

**In Texas, the Preferred Provider Organization (PPO) plan is known as the Participating Dental Network (PDN). 

Yes. Your plan may have one or both of these age limits:

Orthodontic age limit: When the plan includes an orthodontic age limit, braces must be placed on your teeth before reaching your plan's specified age limit.

Dependent age limit: Orthodontic benefits will be available until your dependent reaches your plan's specified age limit. No benefits will be paid after that, even if the treatment is not complete.

Legal notices

Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company and its affiliates (Aetna).

This material is for information only. Health information programs provide general health information and are not a substitute for diagnosis or treatment by a physician or other health care professional. Information is believed to be accurate as of the production date; however, it is subject to change.