Parents may ask when Medicaid or my private health insurance cover braces.

The question comes up when the family does not have a dental plan with orthodontic coverage. You cannot buy a new plan without waiting periods before benefits begin.

Therefore, it makes sense to determine what help your existing medical plan might offer right away.

It never hurts to ask. The answer may yes for certain people and circumstances.

  • Adults can find coverage for medically necessary treatment
  • Children have more options via both private and public programs

Private Health Insurance for Orthodontia

Private health insurance rarely pays for any form of dental work – much less the far more expensive orthodontic procedures. However, there are exceptions to every rule.

Also, adults (rarely) and children (more frequently) can sometimes turn to their medical plan to help to pay for braces. Two tax-favored healthcare programs help many more families.

Covering Adults

Health insurance may cover braces for adults when medically necessary. Medically necessary means the orthodontic procedure prevents, diagnoses, or treats an injury, disease, or symptoms.

Below are examples of possible medically necessary conditions common with adults. You need to make the case that straighter teeth will treat the malady or relieve the symptoms.

  • Non-biting accidents that affect the positioning of your teeth in the mouth
  • Temporomandibular Joint Disorders (TMJ or TMD) requiring bite adjustments
  • Sleep apnea when crooked teeth restrict or block airflow

Most health insurance plans do not include coverage for any cosmetic orthodontic procedures for adults. Cosmetic treatments improve aesthetics only.

  • A nicer smile to improve appearance will not qualify
  • Invisible or clear appliances improve appearance during treatment and do not qualify
    • Invisalign uses clear plastic trays
    • Ceramic braces match tooth colors
    • Lingual braces rest behind the teeth

Covering Children

Health insurance may cover braces for kids as an option. The Affordable Care Act (ACA) requires dental coverage as an essential health benefit for children 18 years old or younger. The company must offer a plan but you do not have to buy it.1

You may select between combination and stand-alone dental plans covering your kids. The criteria for when the plan must cover any medically necessary orthodontia vary by state but may include these rules.2

  • Overjet equal to or greater than 9mm
  • Reverse overjet equal to or greater than 3.5 mm
  • Posterior crossbite with no functional occlusal contact
  • Lateral or anterior open bite equal to or greater than 4 mm
  • Impinging overbite with either palatal trauma or mandibular anterior gingival trauma
  • One or more impacted teeth with an eruption
  • Defects of cleft lip and palate
  • Craniofacial anomalies or trauma
  • Congenitally missing teeth

Low-income families may qualify for help affording this coverage.

Sign up through your state insurance exchange during the annual open enrollment. It begins November 1 and ends December 15.  People who experience a qualifying life event can enroll outside of these dates.

Health Savings Account

Patients can use a Health Savings Account (HSA) to pay for braces. An HSA is a tax-advantaged medical savings program attached to a qualifying high-deductible health insurance plan.3

You must accumulate sufficient HSA funds in the account before you can use the money. In addition, the orthodontia expenses probably will not count towards the deductible. Keep in mind the 2018 annual contribution limits.

  • Individual: $3,450
  • Family: $6,900

Patients can also use a Health Care Flexible Spending Account (FSA) to pay for braces. An FSA is another tax-advantaged program for unreimbursed medical expenses that has one big advantage over an HSA.

An FSA provides interest-free financing for braces with no credit check. You can use FSA funds before making any pretax contributions. Repay your employer using pre-tax payroll contributions and save money on your taxes!

Medicaid Coverage for Braces

Medicaid coverage for braces varies widely based on where the family resides and the age of the patient. The federal government jointly funds the program with each state. Each state government then determines rules for age limits, point system qualifiers, and documentation requirements.

Finding an orthodontist that accepts Medicaid is another issue.

Adults

Medicaid covers adult orthodontic treatment for medically necessary reasons across the country, and for cosmetic purposes in only two states.

  • The rules for medically necessary reasons follow the guidelines noted above.
  • Oregon and the District of Columbia include coverage for cosmetic motives. The orthodontist will have to demonstrate a “handicapping malocclusion” according to the local rules. See more about the criteria in the section below.

Low-income adults living in other regions of the country will have to fund 100% of the costs themselves for any treatments deemed cosmetic.

Children

Medicaid covers braces for children across the country. The Early and Periodic Screening, Diagnosis, and Treatment Program (EPSDT) mandates coverage for orthodontia. The program must pay for treatment when a covered child has a “handicapping malocclusion.”4

Each state determines the age limits, qualifying criteria, and documentation requirements.

Age Limits

Different age limits in each state determine whether your child qualifies for braces via Medicaid. These age restrictions apply to when the treatment starts.

Age LimitNumber of States
Before 2142
Before 204
Before 182
Before 161

Point System

Many states Medicaid programs utilize a 26-point system to determine whether your child has a handicapping malocclusion. Others use different methods to index the need for braces.

  • Handicapping Labio-lingual Deviation (HLD)
  • Salzmann Index

Documentation

Each state Medicaid program will have unique requirements for the type of documentation. These records enable the plan administrator to provide a written pre-certification before beginning treatment for your child.

The orthodontist will need to prepare some or all of these records.

  • Plastic study models of teeth
  • Cephalogram: X-rays of the jaw
  • Panoramic radiograph of the mouth
  • Intraoral photographs

Participating Providers

Finding a local orthodontist near you that accepts Medicaid to treat your child will be difficult. Many practices do not treat Medicaid patients because of the strict qualifying criteria and low reimbursement rates. In addition, the long treatment periods cause billing and collections issues.

Private companies administer most plans. Identify the carrier and utilize their “Provider Directory” to find a participating practice in your area.

CHIP

The Children’s Health Insurance Program (CHIP) provides low-cost health care to teens and kids in families that earn too much money to qualify for Medicaid. Each state offers CHIP and establishes unique rules.

Chip covers orthodontics when medically necessary. Expect to follow similar rules for age limits, point systems, and documentation.

Sources:

  1. ACA Dental Benefits
  2. American Association of Orthodontists
  3. IRS HSA rules
  4. National Center for Biotechnology Information