Medicaid provides essential but not comprehensive dental care in most states, and orthodontic braces often fall 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, or you live in Oregon or Washington DC.
Low-income families with children can take advantage of orthodontic coverage more frequently because a laxer standard of handicapping or functional malocclusion often applies.
Meanwhile, each state establishes rules about which benefits to offer and what makes a patient eligible for reimbursement. Therefore, the trick to finding nearby orthodontists accepting Medicaid requires an understanding of local policies and procedures.
When Medicaid Covers Braces
Medicaid covers dental braces across the country for both children and adults, but only under narrowly defined circumstances for each group. Access to financial assistance could plug the gap for some low-income families who do not meet these qualifications.
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
Medical necessity is the critical factor determining whether Medicaid will pay for treatment, a complex topic discussed in detail in a related article. In summary, two broad definitions can come into play that corresponds with this public program’s hybrid nature.
- Health insurance: prevent or treat an injury, disease, or symptoms
- Orthodontic insurance: correct a severe handicapping malocclusion
Adults Over 21
Medicaid often covers dental braces for adults nationwide when the orthodontic treatment treats and an injury, disease, or related symptoms. In this case, the hybrid program is acting like health insurance.
For example, someone over the age of 21 could expect reimbursement for dislodged teeth repositioning after an accidental injury to the jaw. Likewise, the public program might also pay to remove braces before radiation or chemotherapy to treat cancer.
However, Medicaid pays to correct a handicapping malocclusion in adults in only two regions: Oregon and Washington DC. Low-income individuals over 21 living in the forty-nine other states do not have this form of orthodontic coverage.
Choosing a low-price budget-friendly treatment alternative is the best way for adult recipients to afford that perfect smile they always wanted.
Medicaid covers dental braces for children following a similar overall pattern concerning the two primary reasons to honor claims, but with plenty of variation in each subset.
Reimbursement of orthodontic treatment for children is uniform nationwide when the health insurance component addresses a covered accident or illness. However, the list of related sicknesses is unique to adolescents.
- 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 often pays for dental braces across the country for children who have a handicapping malocclusion. However, the age cutoff for kids varies by state, as does the acceptance criteria – leading to extensive variation.
|Age Limit||Number of States|
Monthly payment plans are the primary alternative for low-income parents who lack the resources to fund the cost of treatment for their kids who do not meet either set of criteria.
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, Medicaid recipients should expect to pay the full cost of Invisalign and other premium solutions 100% out-of-pocket, which should prove unaffordable for any family meeting the low-income qualifying criteria.
Compare the price-points for vanity. A family living at or near the federal poverty level has an obvious choice; take advantage of the average reimbursement of $2,100 for metal appliances, or pay 100% for less noticeable solutions.
$3,000 to $7,000
$1,800 to $2,400
$3,200 to $7,300
$3,400 to $7,100
$4,000 to $8,000
$8,000 to $10,000
Orthodontists Accepting Medicaid
The process of finding a local orthodontist accepting Medicaid offers another opportunity to convey two fundamental truths about how this joint federal and state program works.
First, relatively few dentists participate as in-network providers with public dental plans for several reasons.
- Reimbursement rates are meager
- Some states restrict balance billing of copayments
- Recipients tend to miss scheduled appointments
- Patients often lose eligibility before treatment concludes
Second, each state has tremendous leeway over which benefits to provide, the qualifying criteria for reimbursement, the amount patients must self-fund, and how it chooses to administer the program – as illustrated by the examples below.
New York Medicaid covers orthodontic braces for children under the age of 21 with a severe handicapping malocclusion. Although, retreatment for relapsed cases is ineligible.
- Three years to reposition teeth
- One year for retention services
NY recipients get dental braces free of charge because 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.
However, finding a local provider may prove more challenging because New York law restricts reimbursement to board-certified or board-eligible orthodontists. In other words, you cannot use your local general dentist.
North Carolina Medicaid pays for dental braces for children under the age of 21 with a functional malocclusion, which is a different and sometimes stricter standard to meet compared to other states. In other words, a local orthodontist may be reluctant to accept new patients with mild cases.
NC adolescents with two or more of these anomalies in their mouth 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
Medicaid in California pays for braces for children 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
Recipients can find local orthodontists that accept Medi-Cal Dental by visiting the Smile, California website. Follow the links in the footer section titled “Find a Dentist” and input your zip code into the web-based form.
Medicaid provides dental benefits to children under the age of 20 and younger through the Texas 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 Texas Medicaid might only pay for braces deemed medically necessary when connected to a covered accident or sickness and not a handicapping malocclusion.
Also, be careful when using the online participating provider directory. You can find many local practices accepting the publically-funded dental plan that also perform orthodontic work. However, the insurance might pay for preventive, diagnostic, and therapeutic care, but not braces.
Medicaid in Florida covers braces for children under the age of 21 with a handicapping malocclusion. All eligible recipients must enroll in a dental plan that includes orthodontic care.
Florida families looking for a local orthodontist that accepts their coverage should access the online provider directory for the company administering their plan. Recipients choose a private company when enrolling.
- MCNA Dental
In conclusion, the United States is a constitutional republic with a strong central government that balances states’ rights to govern and tax citizens. The Medicaid entitlement reflects this structure with a nationwide program that includes plenty of regional variation – especially as it relates to orthodontic braces.
Medicaid may pay for braces to straighten teeth under the program’s healthcare arm for both children and adults across the country when a covered accident or sickness causes the need. However, each state establishes age ranges and definitions for malocclusions that fall into the dental coverage category.
The first step in finding a local participating orthodontist is the provider directory published by the private company administering the plan in your state. Then, work with the dentist to submit the documentation needed for possible claim approval.