Orthodontic treatment, like traditional braces, is a significant investment in your or your child’s long-term oral health and confidence. The cost can be a major hurdle for many families. This is where dental insurance can play a crucial role. If you have dental coverage through MetLife, you likely want to know exactly how much it will help pay for braces.
The answer is not a flat number. It depends on the specific MetLife plan you have, whether you choose an in-network or out-of-network orthodontist, and the terms of your policy. This guide will break down how MetLife orthodontic coverage works, what you can expect to pay out of pocket, and how to navigate the process to maximize your benefits.
Understanding MetLife Orthodontic Coverage
MetLife offers a variety of dental insurance plans, primarily through employers. Some are PPO (Preferred Provider Organization) plans, and others are DHMO (Dental Health Maintenance Organization) plans. Orthodontic coverage, if included, is structured differently than coverage for fillings or crowns.
How Much Do Braces Cost When Covered By Metlife Insurance?
Key Features of Orthodontic Coverage:
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Lifetime Maximum: Unlike other dental services that have an annual maximum, orthodontic coverage usually has a lifetime maximum. This is a fixed dollar amount that the insurance company will pay for your entire orthodontic treatment, no matter how long it lasts.
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Percentage Co-insurance: MetLife typically pays a percentage of the total cost of treatment, up to the lifetime maximum. The most common split is 50%.
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Age Limits: Many plans only cover orthodontics for children under a certain age (often 19). However, more and more plans are now offering adult orthodontic coverage as a benefit.
The Typical Cost Structure with a MetLife PPO Plan
Let’s assume you have a common MetLife PPO plan that includes orthodontic coverage with a 50% co-insurance and a $2,000 lifetime maximum.
Here is how the math works for a typical case of braces that costs $5,000.
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Total Cost of Braces: $5,000
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MetLife Co-insurance (50%): $2,500
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MetLife Lifetime Maximum: $2,000
In this scenario, MetLife would pay $2,000** (the maximum), and you would be responsible for the remaining **$3,000.
The lifetime maximum is the critical number. Once MetLife has paid out $2,000 for orthodontics, they will not pay any more for that person’s orthodontic treatment, ever. Even if the treatment lasts longer or costs more than expected, you are responsible for the rest.
The Importance of In-Network vs. Out-of-Network
The calculations above assume you are seeing an orthodontist who is in-network with your MetLife plan. This is a significant factor.
In-Network Orthodontist
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Has a contract with MetLife.
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Has agreed to accept MetLife’s negotiated (“contracted”) rates for services.
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The 50% co-insurance is based on this lower, negotiated rate. This saves you money.
Out-of-Network Orthodontist
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Does not have a contract with MetLife.
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Charges their own “usual and customary” fees, which may be higher.
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MetLife will still pay its 50% co-insurance, but it will be based on its own “reasonable and customary” (R&C) fee schedule for your area, which may be lower than the orthodontist’s actual fee.
Example:
An in-network orthodontist’s contracted rate for braces is $5,000. MetLife pays 50% ($2,500, up to the max), you pay $2,500.
An out-of-network orthodontist charges $6,000 for braces. MetLife’s R&C fee for your area is $4,500. MetLife pays 50% of the R&C fee, which is $2,250. You are responsible for the rest of the $6,000 fee, which is $3,750.
By staying in-network, you save $1,250 in this example.
How to Find Out Your Exact MetLife Benefits
The best way to get a precise answer for your specific plan is to contact MetLife directly. Here is a step-by-step guide.
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Call the number on your MetLife dental ID card. This is the most reliable way to get information specific to your policy.
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Ask these specific questions:
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“Does my plan include orthodontic coverage for myself and my dependents?”
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“Is there an age limit for orthodontic coverage?”
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“What is the lifetime maximum for orthodontic treatment?”
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“What percentage of the treatment cost does MetLife pay (co-insurance)?”
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“Is my orthodontist in-network?”
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“Is there a waiting period before orthodontic benefits can be used?” (Some plans require you to be enrolled for 12 months before using orthodontic benefits).
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Ask the orthodontist’s office to submit a pre-authorization. This is a formal request to MetLife to confirm the estimated coverage for your specific treatment plan. MetLife will send you a written response stating exactly what they will pay. This is the best way to avoid surprises.
A Cost Comparison Table
To illustrate the potential out-of-pocket costs, here is a table based on a $5,000 treatment plan with different MetLife plan structures.
| Plan Structure | MetLife Co-insurance | Lifetime Maximum | MetLife Pays | Your Cost |
|---|---|---|---|---|
| Plan A (Low Coverage) | 50% | $1,000 | $1,000 | $4,000 |
| Plan B (Common) | 50% | $2,000 | $2,000 | $3,000 |
| Plan C (High Coverage) | 50% | $3,000 | $2,500 | $2,500 |
| Plan D (No Ortho Benefit) | 0% | $0 | $0 | $5,000 |
Important Note: The cost of braces varies. Complex cases requiring longer treatment or the use of ceramic braces or Invisalign will have a higher total cost. The MetLife lifetime maximum does not increase for these cases, so your out-of-pocket cost will be higher.
What About Invisalign?
MetLife generally covers Invisalign under the same orthodontic benefit as traditional braces, provided your plan includes orthodontic coverage. The same co-insurance and lifetime maximum will apply.
However, you should be aware of one potential issue. Some insurance plans consider Invisalign to be a “cosmetic” alternative to braces and may apply a lower benefit or exclude it entirely. Ask your MetLife representative specifically: “Is Invisalign covered under my orthodontic benefit at the same level as traditional braces?”
Managing the Cost of Braces
Even with insurance, your out-of-pocket cost for braces can be substantial. Here are ways to manage it.
1. Use a Flexible Spending Account (FSA) or Health Savings Account (HSA)
If your employer offers an FSA or HSA, you can set aside pre-tax dollars to pay for orthodontic treatment. This can save you 20-30% on your out-of-pocket costs. You can use these funds for your co-insurance, deductibles, and monthly payment plans.
2. Payment Plans
Almost all orthodontists offer in-house payment plans with no interest. They will take the total cost of your treatment, subtract what MetLife is expected to pay, and divide the remaining balance into monthly payments over the course of your treatment.
3. Discount for Payment in Full
Ask if the orthodontist offers a discount for paying your entire portion upfront. A 5-10% discount is common. This could save you hundreds of dollars.
4. Consider a Dental School
If cost is a major barrier, orthodontic treatment at a dental school is significantly cheaper. The work is done by students under expert supervision. The process is slower, but the savings can be 50% or more. However, they may not accept your MetLife insurance.
The Value of Orthodontic Treatment
While the cost of braces is high, it is an investment in more than just a pretty smile. Straight teeth are easier to clean, reducing the risk of cavities and gum disease. Correcting a bad bite can prevent jaw pain, headaches, and excessive wear on your teeth. The confidence that comes from a healthy smile has immeasurable value.
Conclusion
The amount your MetLife insurance will pay for braces depends entirely on your plan’s lifetime orthodontic maximum, its co-insurance percentage, and whether you use an in-network provider. For a common plan with a $2,000 lifetime maximum and 50% co-insurance, you can expect MetLife to pay $2,000 towards a $5,000 treatment, leaving you with $3,000 to pay. Always verify your specific benefits with MetLife and get a pre-authorization from your orthodontist before starting treatment.
Frequently Asked Questions (FAQ)
1. Is there a waiting period for MetLife orthodontic coverage?
It depends on your plan. Some employer-sponsored plans have a waiting period of 6 to 12 months before you can use orthodontic benefits. This is especially common if you are a new employee who has just enrolled. Check your plan documents or call MetLife to find out.
2. What happens to my orthodontic coverage if I change jobs?
Your MetLife dental insurance is likely tied to your employer. If you leave your job, you will lose that coverage. You may be able to continue it through COBRA, but you will have to pay the full premium yourself. If you are mid-treatment, you will be responsible for the remaining cost unless you have a new insurance plan that will pick it up.
3. Can I get braces for purely cosmetic reasons with MetLife?
MetLife does not judge the reason for your orthodontic treatment. If your plan has an orthodontic benefit, it will pay its portion of the cost for any qualifying treatment, whether it is for health or cosmetic reasons, as long as it is performed by a licensed orthodontist.
4. Is my child covered under my MetLife plan?
If you have a family plan, your dependent children are typically covered. However, the orthodontic lifetime maximum is applied per person, not per family. So, each child who needs braces would have their own separate lifetime maximum.
5. What if I start treatment and then lose my job?
This is a risk. Your treatment plan is with the orthodontist, not the insurance company. If you lose your coverage, you are still responsible for the full balance of your contract with the orthodontist. Your orthodontist’s office will likely work with you to adjust your monthly payment plan, but the total cost will not decrease.
Additional Resource:
To find an in-network MetLife orthodontist in your area or to learn more about your dental benefits, you can visit the MetLife website at www.metlife.com.
