Does Medicaid Cover Braces Overview
The answer is yes, well, sort of. Medicaid coverage for braces requires that the orthodontic treatment be deemed medically necessary by a qualified dental specialist following Medicaid guidelines. This determination is based on specific criteria that demonstrate the treatment is not merely for cosmetic purposes but is needed to address a medical issue or functional impairment.
Medicaid also considers your age and state and why you want to straighten your teeth.
Even if an orthodontist recommends that Medicaid pay for your braces, your local Medicaid office will still need to approve it.
This is because Medicaid is provided state-by-state, so decisions on what will and won’t be covered vary greatly.
Medicaid’s coverage criteria for braces are based on medical necessity and do not vary with income level.
Some states also have special provisions for children who come from low-income families.
Coverage is hard to come by, even if braces are medically necessary, even for children. Also, if you want Medicaid to pay for aesthetic braces, you will be disappointed.
When Does Medicaid Cover Children’s Braces
Federal law requires all states to provide dental benefits to children enrolled in Medicaid; CHIP (Children’s Health Insurance Program) is a separate program that also includes dental benefits. Some of these benefits include:
1. Routine teeth check-ups.
2. Teeth restoration.
3. Teeth Cleaning.
4. Relief from tooth pain and infection.
Medicaid covers orthodontic services, including braces, primarily for children under 21 as part of the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit. The assessment and recommendation typically come from a dental professional rather than a general physician.
However, medical conditions that qualify people for Medicaid coverage for orthodontic procedures vary state by state.
Medicaid usually pays for kids’ braces when required to correct a disease, injury, or handicapping malocclusion.
Dental problems that interfere with normal mouth functions, such as chewing, swallowing, and other routine activities, may require fixing braces.
Such problems may include:
1. Jaw problems.
2. Cleft palate or lip.
3. Overjet protrusions.
4. Congenital defects.
5. Severe crossbites, underbites, and overbites.
6. Missing or extra teeth due to pre-existing genetic conditions
When Does Medicaid Cover Adult Braces
Medicaid generally covers orthodontic procedures only for children under 21 as part of EPSDT, with very limited circumstances for adult coverage.
However, in the case of braces, adults rarely qualify for Medicaid.
Medical necessity is a critical factor in determining whether Medicaid will pay for braces in adults.
For instance, Medicaid can pay for braces for adults with dislodged teeth or broken jaws due to an accident.
Adults with jaw and neck ailments also have a valid reason to claim dental coverage by Medicaid.
Medicaid will also pay for teeth repositioning procedures to correct the following conditions:
1. TMD or TMJ (Temporomandibular joint disorders).
2. Sleep Apnea.
3. Handicapping Malocclusions.
When presenting your case for Medicaid to pay for your braces, ensure the data is detailed about a medical condition impacted by problems with the mouth or jaws.
Braces can be approved without treatment if you’re experiencing pain, are ill, or have an infection.
Also, if the condition impacts the normal functioning of your body or your ability to go about your routines, then braces can also be approved by Medicaid.
What Doesn’t Medicaid Cover
Again, braces are approved for medical reasons only. Some of the procedures concerning orthodontics that Medicaid won’t pay for include:
1. Treatment to correct crowded teeth.
2. Braces are meant for aesthetic purposes.
3. If the patient has shown a lack of enthusiasm to maintain oral health and hygiene standards.
Medicaid does not cover orthodontic treatments like Invisalign as it typically only covers traditional braces, considered less expensive.
How Can You Determine If You Qualify for Braces with Medicaid
In 2019, the AAO (American Association of Orthodontists) sought to clarify what constitutes a medically necessary orthodontic procedure.
While individual states administer their Medicaid programs and determine some coverage specifics, federal guidelines set minimum standards, including for medically necessary orthodontic treatment in children.
A free consultation with a Medicaid-approved orthodontist can help you better understand whether you should get braces and whether your Medicaid plan will pay for all or a fraction of the expenses.
Medicaid coverage for braces, when approved, generally covers the necessary portion of the treatment under its guidelines.
However, considering that the out-of-pocket costs for braces range from around $5,000 to $7,000, a third-party dental insurance plan can save you a lot of money.
There are other options you should consider to manage dental expenses if Medicaid doesn’t pay, and they include:
1. Getting your dental services from university dental school clinics
2. No-interest financing
3. Cash discounts
4. Tax-exempt saving accounts
Also, non-profit programs such as Smiles for a Lifetime and Smiles Change Lives can offer you cut-price braces if you are a low-income individual who needs braces and can’t afford the entire cost of orthodontic treatment.
Final Thought
To sum it up, each US State establishes laws about which dental services are covered in braces and what makes you eligible for coverage.
So, you need to contact your local office for a final answer on whether Medicaid will pay for your braces.
US Map for Dental Grants (by State)
Dental Grants by State
See Also
Does Medicaid Cover Dental Implants
Does Medicare Cover Hearing Aids
Does Medicare Cover Dental Implants
How to Get Dental Implants Covered by Insurance
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