Does Medicaid cover braces? The answer is – it depends on your age, the state where you live, and the reason you need to straighten your teeth.
This public benefit program provides essential but not comprehensive dental care in most states, and orthodontists’ work often falls into a gray area.
Adults hoping to have Medicaid pay for treatment will often strike out – unless a covered accident or illness drives the need to reposition your teeth.
Meanwhile, low-income families with children can take advantage of orthodontic coverage more frequently because laxer standards often apply.
Each state establishes rules about which benefits to offer and what makes a patient eligible for reimbursement. Therefore, you ultimately need a local resource for the final answer.
When Medicaid Covers Braces for Adults
When does Medicaid cover braces for adults over age 21? This publically-funded program has a dual nature leading to two different answers.
- The health insurance component pays for orthodontia when medically necessary across the country
- The dental insurance component sometimes pays for handicapping malocclusion for children only
Medicaid does not appear to cover braces for adults with a handicapping malocclusion in any state, region, or district. The individuals must have a deformity that affects their oral health and or interferes with chewing or speech.
The majority of low-income adults will find support to straighten crooked teeth unless connected to a medical issue. Therefore, you may need to seek alternatives.
- Financial assistance programs could lower costs
- Payment plans can spread costs out over time
- Supplemental orthodontic insurance rewards planners
Also, each state defines the age when a person becomes an adult and the program stops honoring claims for treatment performed by an orthodontist.
|Age Limit||Number of States|
Medicaid covers braces for adults over 21 when medically necessary in all fifty states. In this case, the hybrid program is acting like health insurance, not a dental plan.
Medically necessary orthodontia procedures prevent, diagnose, or treat an injury, disease, or its symptoms. A doctor would have to refer the patient to an orthodontist to address a covered health condition after conventional medical therapies fail.
- Reposition your teeth into the correct alignment to restore proper chewing function after a non-biting accident
- Temporomandibular Joint Disorders (TMJ or TMD) requiring bite adjustments
- Sleep apnea when crooked teeth restrict or block airflow
- Remove braces before radiation or chemotherapy to treat cancer
Medicaid does not cover Invisalign and other premium orthodontic options in any state for adults or children. The publically-funded program pays for the least expensive treatment alternative, which is metal braces in most cases.
Therefore, recipients should expect to pay the total cost of Invisalign and other premium solutions 100% out-of-pocket, which should prove unaffordable for most households meeting the low-income qualifying criteria.
When Medicaid Covers Braces for Children
Medicaid covers braces for children more frequently than for adults. The Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program requires states to pay for orthodontic services necessary to prevent disease, promote oral health, and restore oral structures to health and function.
In other words, each state can come up with a unique standard as this definition leaves plenty of room for interpretation.
How much do braces cost with Medicaid? Once again, the answer for parents with children depends on many factors. But one thing is sure – the orthodontic treatment is not free.
- States can impose cost-sharing features (deductible, copayments, etc.)
- Covers orthodontia for kids meeting strict criteria
- Congenital issues present
- Exceed point system cutoff
- Pays for the least expensive treatment alternative
The chart below can help you estimate how much braces will cost for your child – if Medicaid pays for the least costly treatment (tinsel teeth).
|Metal||$3,000 to $7,000||$1,800 to $2,400|
|Gold||$3,200 to $7,300||$0|
|Invisalign||$3,400 to $7,100||$0|
|Ceramic||$4,000 to $8,000||$0|
|Lingual||$8,000 to $10,000||$0|
Medicaid covers braces for children that suffer from congenital problems present at birth uniformly across the country. In these scenarios, the public benefits program is acting like health insurance.
Therefore, if one of your kids has one of these conditions, your state’s perspective about paying for dental work is not an issue.
- 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
Medicaid sometimes covers braces for children whose handicapping malocclusion qualifies under a point system or a criteria-based objective benchmark. Each state defines rules on whether to include orthodontia and, if so, the standard of misalignment needed to qualify.
Your local orthodontist should be familiar with the rules in your state and help you assemble the documentation needed to support a claim.
- Plastic study models of teeth
- Cephalogram: X-rays of the jaw
- Panoramic radiograph of the mouth
- Intraoral photographs
Medicaid in California pays for braces for teens who qualify (handicapping malocclusion) as part of the Medi-Cal dental program. However, not every adolescent has orthodontic coverage.
- Babies (0 – 4): No
- Kids (5 – 12): No
- Teens (13 – 17): Yes
- Adults (18 – 54): No
- Pregnant women: No
Texas Medicaid provides dental benefits to kids under the age of 20 and younger through the Health Steps program, which supports plans administered by two private companies.
- MCNA Dental
Both companies publish member booklets that highlight what their dental plans do cover: preventive, diagnostic, and therapeutic benefits to ensure healthy teeth. However, orthodontic treatment is not listed.
Therefore, we conclude that the Texas program might only pay for braces deemed medically necessary; when connected to a covered accident or sickness and not a handicapping malocclusion.
Medicaid in Florida pays for braces for teenagers under the age of 21 with a handicapping malocclusion. All eligible recipients must enroll in a dental plan that includes orthodontic care.
Contact the private company administering your plan for details about how Florida determines eligibility.
- MCNA Dental
New York Medicaid pays for orthodontic braces for adolescents under 21 with a severe handicapping malocclusion. Although, retreatment for relapsed cases is ineligible.
- Three years to reposition teeth
- One year for retention services
In NY all participating orthodontists agree to accept the plan reimbursement as payment in full. In other words, they cannot send a separate bill to patients for any portion of treatment, including placement and removal.
Georgian Medicaid does not appear to pay for braces for kids with a handicapping malocclusion. The state-published handbook indicates the program includes preventive dental care, fillings, and oral surgery for children.
Notice that orthodontia is missing from the list of covered dental services. Therefore, we conclude that Georgia includes coverage for braces only when medically necessary.
North Carolina Medicaid pays for dental braces for teenagers under the age of 21 with a functional malocclusion, which is a different and sometimes stricter standard to meet compared to other states.
NC adolescents with two or more of these anomalies have the best odds of approval.
- Severe skeletal conditions
- Class II or Class III anterior-posterior occlusal discrepancy
- Anterior cross-bite that involves more than two teeth
- Open-bite 4 mm or greater
- Over-jet protrusion 6 mm or more
- Crowding greater than 6 mm in either arch
- The excessive anterior spacing of 8 mm or greater
- Psychological and emotional factors causing psychosocial inhibition