Does Medicaid Cover Braces?

Although Medicaid is a backstop health care program run by the federal government, not all Medicaid plans are alike. Coverage varies from state to state because some states elect to provide adult dental benefits and others do not.

All states must provide dental coverage to children under Medicaid and the Children’s Health Insurance Program (CHIP). States must pay for dental braces and orthodontics under Medicaid if they are deemed medically necessary. Again, each state gets to define for itself what medical necessity is. Some states define children as anyone younger than 18, but others cover individuals up to 21 years of age.

The comprehensive set of benefits for children, known as the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefits, cover all dental services provided they are determined as medically necessary. In such cases, the program serves as a health insurance plan as opposed to a dental plan.

Overall, some states that do provide dental coverage for adults under Medicaid may include dental braces and orthodontic treatments if they are medically necessary.

Medicaid Health Plans

As of June 2020, 68 million people in the United States receive health care coverage through Medicaid. Medicaid provides affordable health coverage to qualifying low-income adults, children, elderly individuals, people with disabilities, and pregnant women.

Medicaid is funded in part by the federal government and in part by each state. States must meet federal requirements for how Medicaid health plans are administered, though states have some discretion over which benefits they choose to offer.

For adults, dental care coverage varies by state. States can choose whether they provide dental benefits or not. Again, states are required to provide dental benefits to all children who receive health coverage through Medicaid and CHIP.

Medicaid Dental Coverage

Children covered by Medicaid and CHIP automatically receive dental benefits as part of the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit. Children must receive a referral from their primary doctor to see a dentist for routine dental exams.

These basic dental services must be provided to children covered by Medicaid:

• Dental health maintenance
• Pain relief services
• Treatment of infections
• Teeth restoration services

In addition to the above basic services, all services that are determined medically necessary must be covered. During routine screenings, for example, conditions that require additional treatment might be discovered. The costs of those medically necessary treatments must be covered by Medicaid. What is considered to be medically necessary, however, varies by state.

According to Medicaid.gov, less than half of states currently provide comprehensive dental care to adults. Most states do provide some level of coverage for emergency dental services, but there are unfortunately no minimum requirements for adult dental coverage.

Medicaid Coverage for Braces

Medicaid coverage for braces and orthodontic treatment is based on state funding, and coverage options vary from state to state. There is no standard for Medicaid treatment and braces coverage, however. To be considered for braces, the treatment must be considered medically necessary.

This can include the following dental issues:

• Malocclusion due to trauma or injury
• Craniofacial abnormalities or deformities
• Misaligned teeth in conjunction with another medical condition or syndrome
• Malocclusion deemed to be severely handicapping and impacting physical and/or emotional well-being
• Congenital conditions, such as cleft palate or missing teeth
• Overjet and reverse overjet of specific measurements
• Crossbite in the back of the mouth that keeps teeth from matching up

It can be difficult to know what is going to be considered medically necessary and therefore what will be covered through Medicaid. Generally speaking, dental conditions causing extreme difficulties with everyday life, such as problems eating or talking, are most likely to be considered medically necessary. Braces for aesthetic purposes are less likely to be considered.

Some states do provide braces for low-income children. To find out if you live in one of these states, contact your Medicaid caseworker or state health department.

Orthodontic Insurance

If the cost of braces is not covered by the Medicaid plan in your state, you could purchase a supplemental orthodontic insurance plan. Even major medical insurance plans rarely include orthodontic coverage for adults and only some offer coverage for children under 18.

Supplemental orthodontic insurance for braces covers the cost of braces for reasons beyond just medical necessity, such as the following reasons:

• To straighten teeth
• To close spaces between teeth
• To correct bite irregularities
• To properly align lips and teeth

Orthodontic insurance plans can help to greatly reduce the overall cost of braces, though they will not likely cover the full cost. These plans are meant to supplement the costs of devices, like braces, that are used to fix abnormalities in the teeth or jaw. Orthodontic insurance plans are offered by most major insurance companies.

How to Pay for Braces or Other Types of Orthodontic Care

Braces can come with a price tag of up to $8,000 or more. Few families have the financial means to pay that much out of pocket.

Fortunately, there are ways to make the cost of braces more affordable. Consider these ways to get braces at a lower price tag:

Medicaid for Braces

Medicaid insurance offers affordable health coverage for millions of Americans. Unfortunately, braces are not typically covered by Medicaid. If you or your child needs braces, you may need to get creative about how you pay for them.

Before you pay thousands of dollars out of pocket for braces, explore some of the available options to reduce the costs. If those options don’t work out, you can always purchase a supplemental orthodontic plan.

You can also look into other forms of orthodontic treatment that are more affordable, such as doctor-monitored, at-home aligners. You may be able to get the straight smile you want with a shorter treatment timeline and lower overall cost than braces. While some cases of misalignment may be too severe to correct with aligners, this form of tooth straightening works well for most people with mild to moderate cases of misalignment.

References

Comparison of Orthodontic Medicaid Funding in the United States 2006 to 2015. (August 2017). Frontiers in Public Health.

Medical Necessity and Orthodontics. (September 2016). Pediatric Dentistry Today (PDT).

Dental Care. Medicaid.gov.

Medicaid. Medicaid.gov.

Organizations That Help Low-Income Children to Get Braces. (July 2017). Pocket Sense.

Supplemental Orthodontic Insurance for Braces: A Must-Have. (June 2020). Health Markets.

Coverage of Medicaid Dental Benefits for Adults (June 2015). Medicaid and CHIP Payment and Access Commission.

Does Medicaid Cover Dental Care? (May 2012). U.S Department of Health and Human Services.

Medicaid and Medicare Enrollees Need Dental, Vision, and Hearing Benefits (December 2020). Center on Budget and Policy Priorities.

Does Medicaid Cover Braces for Adult & Kids in Your State? (April 2021). Growing Family Benefits.