Some Medicaid beneficiaries may have difficulty getting orthodontic treatments like braces, which can cost a lot if paid out of pocket.
This is because eligibility depends on your age, state of residence, and whether the procedure is ‘medically necessary.’
Here we explain how to confirm your eligibility for Medicaid braces coverage, what is considered medically necessary, and how to qualify for free orthodontic care.
Yes, Medicaid covers braces and other orthodontic procedures for low-income adults, kids, seniors, and pregnant women. However, comprehensive dental care coverage varies from state to state. Also, a doctor must recognize the procedure as medically necessary to be eligible.
Meanwhile, it’s not always easy to tell what a medical necessity is and whether a Medicaid plan will cover it.
Doctors usually define medical necessities as deformities that impact the patient’s oral health or interfere with their ability to eat or speak [1]. As a result, Medicaid can pay for the orthodontic treatment if these cases require it.
If your child’s braces treatment doesn’t qualify for the program, you can explore some of the best cheap dental insurance plans to reduce costs.
Certain states offer free braces or low-cost orthodontic treatment for children from low-income families. However, eligibility may vary as most states cover kids up to 21, while others only provide dental coverage up to 18. Consult your local Medicaid provider to see if you reside in one of these states.
Yes. While certain Medicaid plans now include orthodontic braces for adults and other dental benefits, only a few people over 21 get their braces covered [2].
Medicaid covers medically necessary treatments to prevent disease or injury, like broken jaws or dislocated teeth requiring orthodontic treatment.
Some may ask, “does Medicaid cover dental implants for adults?” Dental implants could be a medical necessity covered by Medicaid if the patient needs them to fix a functional impairment affecting basic oral activities.
Medicaid and the Child Health Insurance Program (CHIP) require all states to pay the cost of braces for children to promote oral health.
The program must cover orthodontic treatment for children under 18 or 21 if they need to correct crowded teeth, fix a misaligned jaw, or reposition teeth.
The dental plan also pays for orthodontic procedures and other dental benefits when kids need them to fix dental issues that may affect basic oral activities like eating.
Braces are necessary for kids to restore oral structures or correct issues like cleft palate that affect typical oral activities like talking, chewing, and swallowing. Some of these dental issues may include:
Braces are also necessary for adults with medical conditions like dislocated teeth or broken jaws.
In addition, orthodontic procedures are medically necessary in adults for teeth repositioning to treat medical conditions like:
The first step is to determine if you are on Medicaid or are eligible for the dental plan.
Medicaid offers low-income individuals and families access to low-cost health insurance, including routine cleaning, orthodontic evaluation, teeth restoration, and pain and infection relief.
Contact your orthodontic provider or a healthcare navigator to confirm your eligibility.
To find a health navigator in your area, go to this local help page and enter your zip code.
They will ask about your family size and household income and then tell you if you or your child are qualified for the program. If not, they can help you start the application process.
Finally, after applying, you get a free consultation with a local orthodontist for a thorough teeth evaluation. According to the American Association of Orthodontists, children should have their first orthodontic evaluation by seven. The local orthodontist will decide the medical necessity of your treatment, which is a critical factor for eligibility.
Medicaid is a health insurance program funded by the state and federal government that provides affordable health coverage to low-income people [3]. However, its coverage for dental services varies from state to state, so not all programs are the same.
Medicaid will cover orthodontic treatment, including dental braces, as long as they are considered medically necessary. Generally, dental disorders that make daily tasks like eating and talking nearly impossible are most likely medically necessary.
Each state sets rules concerning which dental procedures are medically necessary and what qualifies you for Medicaid coverage.
As a result, you’ll need to contact your local Medicaid provider to get a final answer regarding what makes a patient eligible for braces coverage.
