Orthodontia mid-treatment example
Mid-treatment with Orthodontia?
The increase to the orthodontia benefit impacts those with dependents mid-treatment. After Jan. 1, 2021, you’ll need to file a new claim with the original banding date, total treatment fee and treatment length. The allowed amount is determined after checking if the provider is in-network.
Note: The enhanced orthodontia benefit if for in-network providers only
EXAMPLES:
Example 1
Employee is covered by plan Option 1 today. Child was banded on June 1, 2020, and the in-network provider is billing $4,000 for a 24-month treatment plan.On Jan. 1, 2021, Purdue’s Option 1 orthodontia coverage increases to $1,600.
2020
Original billed amount: $4,000
$4,000 / 24 months of treatment = $166.66 per month
June - December 2020 (7 months x $166.66 = $1,166.62) Plan pays at 50% = $500.00 (maximum lifetime allowable for 2020)
2021
Employee elects plan Option 1 for 2021.
On Jan. 2, 2021, the orthodontic claim is refiled with 17 treatments left.
17 monthly treatments @ $166.66 each = $2,833.22. Plan pays at 60% = $1,100 (maximum additional lifetime benefit allowable.)
Enhanced orthodontic lifetime benefit is $1,600. Plan pays $500 in 2020 and an additional $1,100 in 2021 for in-network providers.
Example 2
Employee is covered by the preventive only or option 2 plan today with no orthodontia coverage. Employee enrolls in the Option 1 plan for 2021. Will any treatments be covered under the orthodontia benefits? YES
Child was banded on June1, 2020 and the in-network provider is billing $4,000 for a 24-month treatment plan. On Jan. 1, 2021 the employee gains orthodontia coverage under the Option 1 plan of $1,600.
2020
Original billed amount: $4,000
$4,000/24 months of treatment = $166.66 per month
June – December 2020 child was ineligible for orthodontia coverage (7 months x $166.66=$1,166.62 is disallowed)
2021
Employee elects plan Option 1 for 2021 On Jan. 2, 2021, the ortho claim is refiled with 17 treatments left
17 monthly treatments @ $166.66 each = $2,833.34. Plan pays at 60% = $1,600 (maximum lifetime benefit allowable with new election)