Does Medicaid Cover Braces? Adult and Children Braces Coverage

Medicaid, a joint federal and state assistance program, can help pay for dental braces in limited circumstances. Every state has different criteria regarding its Medicaid coverage for orthodontic care, which includes braces. In each case, a medical or dental professional must diagnose a health condition that braces may help resolve. Learn what conditions may make you or your child eligible for free or reduced-cost braces.

Key takeaways:

How do you know if you need braces?

Braces are dental appliances designed to straighten crooked teeth, close gaps between poorly spaced teeth, or realign the jaw. They have brackets and wire that press against the teeth to help the teeth become more properly aligned.

A severe misalignment of the teeth – called a malocclusion or “bad bite” –– may cause problems with chewing and swallowing. It can lead to further oral health complications such as tooth decay or loss, gum disease, or jaw problems. It’s easier to correct this issue during childhood, but at least 25% of people with braces are adults.

Signs that you might need braces include:

  • Jaw pain or clicking when you first wake up or when you chew
  • Teeth not aligning when your mouth is at rest
  • Visibly crooked or crowded teeth
  • Difficulty brushing and flossing
  • Overbite or underbite
  • Speech difficulties
  • Mouth breathing
  • Cleft palate
  • Difficulty chewing food

Does Medicaid cover braces for adults?

Medicaid might pay for dental braces for adults, but this is quite rare. You would need to provide proof that your malocclusion is affecting your overall health, not just your dental health. Even with this evidence, Medicaid may not agree to cover orthodontic services for you.

Most states offer a minimum of emergency dental services in their Medicaid programs, which may provide braces if medically necessary. However, each state determines what is “medically necessary.”

The American Association of Orthodontists defines medically necessary orthodontic care as “services to prevent, diagnose, minimize, alleviate, correct, or resolve a malocclusion (including craniofacial abnormalities and traumatic or pathologic anatomical deviations) that cause pain or suffering, physical deformity, significant malfunction, aggravates a condition, or results in further injury or infirmity.”

Medicaid will not cover braces for cosmetic reasons. For example, the program will not pay for braces only to fix appearance issues due to spacing between teeth, crowded teeth, overbites, or underbites.

Will Medicaid cover braces for children?

Yes, states that provide Medicaid XXI coverage to children must cover dental services, including braces, for Medicaid beneficiaries under the age of 21. This mandatory provision is included in the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit.

According to InsureKidsnow.gov, some states cover braces for children only with prior authorization. Patients must show a severely handicapping orthodontic condition. Braces must address:

  • Treatment for malocclusion
  • Misalignment or malposition of teeth with adverse impact

Children enrolled in a Children’s Health Insurance Program (CHIP) program may also be covered by the EPSDT benefit. However, the Centers for Medicare & Medicaid Services has stated: “States are not required to meet the EPSDT level of services to provide all medically necessary services under their CHIP plans.”

How much do braces cost with Medicaid?

How much braces would cost with Medicaid depends on what your orthodontist would charge, what fees your state's program will pay, and what costs would be your responsibility. Depending on your state’s Medicaid, you might be liable for out-of-pocket costs such as enrollment fees, premiums, deductibles, or copayments.

Under the CHIP program for children, families would have to pay out a maximum of 5% of family income for all medical and dental services combined.

Can you get free braces with Medicaid?

Medicaid may cover dental braces in cases of medical necessity. Dental care under Medicaid is not available in every state, though. States may choose whether to include orthodontic care or any other dental benefits to their adult Medicaid beneficiaries.

This table lists the level of Medicaid dental coverage each state currently offers.

No Medicaid Dental CoverageAlabama, Delaware, Tennessee
Emergency Medicaid Dental CoverageArizona, Florida, Georgia, Hawaii, Idaho, Maine, Maryland, Mississippi, Nevada, New Hampshire, Oklahoma, Texas, Utah, and West Virginia.
Limited Medicaid Dental CoverageArkansas, Colorado, Illinois, Indiana, Kansas, Kentucky, Louisiana, Michigan, Minnesota, Montana, Nebraska, Pennsylvania, South Carolina, South Dakota, Vermont, Virginia, and Wyoming.
Comprehensive Medicaid Dental CoverageAlaska, California, Connecticut, Iowa, Massachusetts, Montana, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oregon, Rhode Island, Washington, and Wisconsin.

How to know if you qualify for braces coverage

Consult your Medicaid plan documents to learn the eligibility requirements for braces coverage. You can also request this information from your local or state Medicaid office.

Steps how to get braces covered with Medicaid

Before you can get braces covered with Medicaid, a licensed orthodontist would need to confirm that your dental condition warrants this treatment. Adults would need to show that getting dental braces is the most economical and effective way to improve a non-dental health problem. Some orthodontists will offer a free consultation.

To get started with determining Medicaid coverage for braces where you live, follow these steps:

  1. Check to see if your state’s Medicaid program has a dental benefit that includes braces.
  2. Ask your health care provider if dental braces may correct a serious health problem.
  3. Find and arrange treatment with an orthodontist who accepts Medicaid.

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Comments

Adrianna hoskins
prefix 8 months ago
I'm 14 year old in I was wondering if my insurance will pay for my braces if I have a gap,overbite and upper canine that hurt when I bite