Does Medicaid Cover Braces? Medicaid coverage for braces is available for individuals under 21 as part of the EPSDT benefit. However, this coverage is not uniform across all states. In some states, Medicaid may cover braces if deemed medically necessary.
This necessity is often based on specific dental or orthodontic issues, like severe overbite problems or difficulties in chewing or speaking. It’s essential to consult with your local Medicaid office to understand your area’s specific criteria and coverage.
We aim to simplify obtaining braces through Medicaid, a vital resource for many families. Medicaid, a government-funded program, offers health coverage to eligible individuals, including orthodontic treatments for those who qualify. Orthodontic care, such as braces, is not just a cosmetic concern; it can improve dental health and overall well-being.
Children’s Health Insurance Program (CHIP) Dental Benefits for Kids
States that use CHIP as part of Medicaid must provide the EPSDT benefit to kids. Dental care in CHIP can help prevent dental diseases, keep teeth healthy, fix teeth problems, and handle urgent dental needs.
States with their own CHIP program have two ways to offer dental benefits: They can either create a dental plan that meets CHIP rules or use a standard plan, called a benchmark dental benefit package. This standard plan should be as good as one of these three options:
- It is the most chosen dental plan for kids in the federal employee program,
- It is the most popular plan for kids in the state’s employee dental plan, and
- The top commercial insurance company in the state offers dental coverage.
The Costs of Braces
Type of Braces |
Cost |
|
At-home clear aligners |
$1,200 – $5,000 |
|
Ceramic braces |
$3,000 – $10,000 |
|
Lingual braces |
$5,000 – $13,000 |
|
In-office invisible braces |
$3,500 – $8,500 |
|
Traditional metal braces |
$2,500 – $7,500 |
Overview of Medicaid
Medicaid is a health insurance program in the U.S. that helps low-income people get free or cheap health care. This care includes adults with low income, kids, pregnant women, older adults, and people with disabilities.
Medicaid and the States – The U.S. federal government and each state pay for Medicaid together. Every state runs its version of Medicaid, but they follow rules set by the federal government. Medicaid helps pay for many health services.
What Health Services are Included? – This care includes going to the doctor, staying in the hospital, getting check-ups to prevent illness, medicine, and sometimes dental, eye, and long-term care. Medicaid is essential for giving health care to people who cannot afford private health insurance.
Who is Eligible? – Who can get Medicaid depends on where you live. Eligibility is based on how much money you make, how big your family is, and a few other things. The Affordable Care Act (ACA) made it easier for many low-income people to get Medicaid in many states. But, not every state decided to make these changes to their Medicaid programs.
Financial Eligibility through the ACA – In 2023, if you’re earning between $13,590 and $54,360 or are part of a family of four making between $27,750 and $111,000, you can check out the help offered by the ACA (Affordable Care Act).
Medicaid for Lower Income Children
Medicaid provides dental care for kids as part of its broad range of health services. This care is known as the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit.
While a doctor might check a child’s teeth during a regular health exam, this is not the same as a complete dental check-up done by a dentist. Following each state’s schedule, kids must be regularly sent to a dentist.
At the very least, children’s dental services under Medicaid should cover:
- Treating pain and infections in the mouth
- Fixing damaged teeth
- Keeping teeth healthy
Navigating the Approval Process
The orthodontist will likely conduct a thorough examination during your initial consultation, including X-rays and dental impressions. If braces are recommended, the orthodontist will submit a request to Medicaid detailing the medical reasons for the treatment.
This process can take some time, and it’s essential to provide all necessary documentation to avoid delays. If your request is initially denied, don’t lose hope. You can often appeal the decision or seek advice from your orthodontist on how to proceed.
Preparing for Braces Treatment
Once approved, your orthodontist will develop a detailed treatment plan. This plan will outline the type of braces you’ll receive, the estimated duration of treatment, and the schedule of follow-up appointments.
While Medicaid covers many aspects of orthodontic care, there may be some out-of-pocket expenses, such as for specific braces or additional procedures not covered by Medicaid.
Finding a Medicaid-Approved Orthodontist
The first step in your journey is to locate an orthodontist who helps low-income children get braces. You can start by contacting your local Medicaid office for a list of approved providers. A consultation with an orthodontist or dentist is essential to determine if braces are necessary for your child. They will assess various factors to decide if orthodontic treatment is required for health reasons. Key reasons to be approved for braces are:
- Presence of a cleft palate.
- Jaw structural abnormalities that hinder mouth opening.
- Difficulties in eating or chewing correctly.
- Speech issues arising from dental or jaw irregularities.
- Significant dental misalignments such as severe underbites, crossbites, or overbites.
- Protrusion of teeth (overjet), where the upper teeth extend over the lower teeth.
- Impacted teeth that are not emerging correctly.
- Absence of teeth due to inherited conditions, like hypodontia.
FAQs
Q: How do I determine if Medicaid covers braces in my state? Contact your state’s Medicaid office or visit their website for the most accurate and up-to-date information.
Q: Can adults get braces covered by Medicaid? It’s rare but possible in specific medical circumstances. Check with your state’s Medicaid program for details.
Q: What if I don’t qualify for Medicaid but can’t afford braces? Explore the Children’s Health Insurance Program (CHIP) or inquire about payment plans and financial assistance with your orthodontist.
Q: Can I get vanity braces? The child must then be referred to a qualifying dentist or specialist for treatment. Malocclusion (teeth misalignment) should qualify as a medical necessity and be covered under Medicaid if an orthodontic issue requires treatment. For more questions, go to the Medicaid website.
You Don’t Qualify for Medicaid – Additional Resources.
For additional resources and detailed information about Medicaid coverage for braces, you can explore the following:
Insurance Blob’s Guide on Medicaid and Braces: This guide offers comprehensive information on Medicaid’s coverage for braces in 2023 if you’re earning between $13,590 and $54,360 or are part of a family of four making between $27,750 and $111,000, you can check out the help offered by the ACA (Affordable Care Act), including copayments, the range for adults, and alternative options if Medicaid doesn’t cover braces for you. Visit Insurance Blob for more details.
Dentaly.org’s Medicaid Braces Coverage Overview: Dentaly.org provides an in-depth analysis of Medicaid’s coverage for braces, including differences between Medicaid and CHIP, what constitutes medically necessary treatment, and other ways to finance braces. For more insights, check out Dentaly.org.
NewMouth’s Explanation on Free Braces with Medicaid: This article explains how Medicaid covers braces, the qualification process, and alternatives for free or low-cost orthodontic treatment. You can read more on NewMouth.
Orthodontic Experts’ Guide on Medicaid Coverage: This resource delves into specifics like appealing Medicaid decisions, eligibility criteria, and finding affordable braces with Medicaid—orthodontic Experts.
MedicareAdvantage.com’s Overview of Medicaid and Braces: This site offers insights into state-specific requirements for Medicaid coverage of braces, range for adults, and Dual-eligible Special Needs Plans for those eligible for both Medicaid and Medicare. For more information, visit MedicareAdvantage.com.
These resources provide a thorough understanding of Medicaid coverage for braces, state-specific regulations, and alternatives if Medicaid does not cover your needs.
Conclusion
Obtaining braces through Medicaid involves several steps, from understanding your coverage to maintaining oral health throughout treatment. While the process can seem daunting, the benefits of orthodontic treatment can be life-changing. Remember, you’re not alone in this journey; many resources are available to help you navigate the system.