Many patients with crooked teeth do not have a dental plan with orthodontia coverage, but most have health insurance through a private company or Medicaid.
Therefore, learning to get braces covered by medical insurance might be the best way to make orthodontic treatment affordable.
You must demonstrate that you have a medically necessary reason, which is more challenging to prove for adults than for children.
Your orthodontist can use our sample letter to improve your claim approval chances, a far better strategy than shopping for a new health insurance plan that covers braces.
Medically Necessary Orthodontia
The primary way to get braces covered by health insurance is to demonstrate that the orthodontia is medically necessary: the procedure prevents, diagnoses, or treats an injury, disease, or symptoms.
Adult Coverage
Adults over nineteen face the steepest hurdles when trying to get braces covered by health insurance because the list of medically necessary reasons is much shorter.
Free braces programs for adults are scarce also, as demand far exceeds the supply at dental schools and clinics. Therefore, you might need to explore alternatives if your needs are more cosmetic.
Payment Plans
Payment plans are a viable alternative for adults when their health insurance denies claims for orthodontia because they do not have a medically necessary reason.
Monthly payment plans for braces spread the treatment costs out over time, making it easier to afford cosmetic treatment. A third-party finance company usually backs the program, relying on referrals from orthodontists who prefer their money upfront.
Dental Insurance
Buying a dental plan with orthodontic benefits is another reasonable option for adults when their health insurance denies claims for braces but requires patience to pay off.
Dental insurance for braces for adults without waiting periods is an unreasonable expectation. Issuing companies want no part of such a deal. However, you might be able to buy a plan that kicks in a year from now, providing significant discounts from in-network orthodontists.
Adult Reasons
Adults might get medical insurance to cover braces when orthodontia treats an injury, disease, or symptom. Some of these situations might qualify if you submit a well-supported letter of medical necessity (see sample letter below).
- Reposition teeth after a non-biting accident such as a broken jaw
- Temporomandibular Joint Disorders (TMJ or TMD) bite adjustments
- Sleep apnea (when crooked teeth restrict or block airflow)
- Removal of braces to treat disease of the head, neck, or jaw
- Before radiation therapy
- Before highly stomatotic chemotherapy
- Complications of IV bisphosphonates
Invisalign
Getting your medical insurance to cover Invisalign for adults will prove incredibly challenging, even when your orthodontist builds an iron-clad case that the proposed treatment is medically necessary.
As a premium option, Invisalign is far more expensive than traditional metal braces. Your orthodontist must show that the clear aligner trays were indispensable and that lower-cost alternatives could not correct your TMJ or sleep apnea.
A Health Saving Account (HSA) sometimes covers cosmetic dental work that falls into a gray area. Even though the Invisalign clear trays serve an aesthetic purpose, they do straighten teeth and qualify for HSA reimbursement.
Child Coverage
Children under nineteen have more opportunities to get health insurance to cover braces because the list of medically necessary orthodontic procedures is longer.
In addition to the accidents and illnesses applicable to adults, children can often get their medical insurance to pay for orthodontic work that corrects congenital deformities that result in physically handicapping malocclusions.
For instance, United Healthcare covers the correction of severe craniofacial deformities resulting from several specific conditions.
- Cleft Lip and or Cleft Palate
- Crouzon Syndrome/Craniofacial Dysostosis
- Hemifacial Hypertrophy/Congenital Hemifacial Hyperplasia
- Parry-Romberg Syndrome/Progressive Hemifacial Atrophy
- Pierre-Robin Sequence/Complex
- Treacher-Collins Syndrome/Mandibulofacial Dysostosis
Health Insurance Questions
People often ask the wrong questions, and what health insurance covers braces is one. Shopping around for a new plan will not make your orthodontia more affordable, but submitting a letter of medical necessity to your existing carrier might!
Medicaid
Medicaid is the only health insurance that covers orthodontic braces without a medically necessary reason. This publically-funded program for low-income families often includes dental benefits that vary by state.
Medical coverage of braces is different for adults than for children.
- You will need a medically necessary reason for adults under the health insurance umbrella.
- Teenagers might qualify with handicapping malocclusions under the dental care element of the program.
Each state defines handicapping malocclusion differently, but all use an indexing or point system that quantifies the misalignment of your child’s teeth.
Find an orthodontist that accepts Medicaid in your area. Then, work with this provider to document the severity of your child’s malocclusion using the point system required by your state. Submit the documentation to the Dental Benefits Manager administering your plan for pre-approval.
Sample Letter
A sample letter of medical necessity is more likely to help your cause than asking what health insurance covers braces for adults. Shopping around for a new plan is a dead end, as issuing companies follow similar claims underwriting rules.
Submit a letter of medical necessity to your existing company to pre-certify your orthodontic treatment plan. Have your orthodontist include as many of these elements in the document as possible.
- Patient name and member ID number
- SOAP Notes (Subjective, Objective, Assessment, Procedure)
- Summary of medical history and diagnosis
- Plastic study models of teeth
- Cephalogram: X-rays of the jaw
- Panoramic radiograph of the mouth
- Intraoral photographs
- Rationale for treatment
- How it treats a disease or illness
- Why is it consistent with the applicable standard of care
- Proposed treatment report
- Appropriate ICD-10 and CPT codes
- Prognosis or expected outcome
