Medicaid provides health care benefits for many low-income families and individuals. Medicaid is a program that is funded jointly by the federal government and each individual state. With many children and adults today needing braces for dental correction, you might be wondering whether or not Medicaid covers braces. The answer depends on a few different factors. The place you live can have an effect on coverage as well as your specific diagnosis. If you need braces, then keep reading! We will give you all the details on whether they will be covered by Medicaid, as well as some other options for paying for them.
Will Medicaid Pay For Braces?
So, does Medicaid pay for braces or other dental services? One of the most significant determining factors is the age of the patient. Therefore, we will examine coverage for braces separately for children and adults below. Many people wonder how to get free braces with Medicaid, so here is what you need to know when it comes to getting braces covered by Medicaid.
— Medicaid & Braces For Children
Under the EPSDT program, Medicaid provides many benefits to children that are not offered to adults. These services provide dental care, screening, and preventive services to children under 21 years of age in every state. This can include braces! However, the medical necessity of the braces will determine whether Medicaid will cover them. If braces are deemed medically necessary for your child, then Medicaid will cover them. Medical necessity will be determined by a dentist or orthodontist registered with the American Association of Orthodontists.
There are several different reasons why braces might be medically necessary. Cosmetic reasons will not qualify your child for coverage under Medicaid. Your orthodontist will look at your child’s records and condition to determine the necessity. Here are some conditions that will usually deem braces medically necessary:
- Cleft palate
- Cleft lip
- Severe overbite, underbite, or crossbite
- Structural jaw issues
- Overjet teeth
- Problems eating or chewing
- Malocclusion
If your child has any of the medical conditions above, then he or she is likely eligible for orthodontic treatment that will be covered by Medicaid. Medicaid will typically only cover metal braces and not clear or ceramic braces. Once you know that Medicaid will pay for braces, you will need to find an orthodontist who accepts Medicaid. Finding a doctor who accepts Medicaid can be difficult, but you can typically visit the website of your carrier to find an online directory.
— Medicaid & Braces For Adults
Are you wondering, ”Does Medicaid cover braces for adults?” Getting Medicaid to pay for braces as an adult is more difficult. In some states, Medicaid does not provide any dental coverage for adults. In those states, you will not be able to get Medicaid to pay for your braces regardless of medical necessity. However, some states provide oral health benefits for adults as well. In those states, your braces must be deemed medically necessary, and it can sometimes be difficult to pass that threshold as an adult. Some conditions that might qualify you for coverage would include the following:
- TMJ
- Sleep apnea
- Broken jaw
Simply because you want to get braces to correct the spacing between your teeth would not qualify you for coverage. Your eligibility as an adult will be limited to only those severe cases where braces are absolutely required for medical reasons.
Does Medicaid Cover Invisalign?
No, unfortunately, Medicaid does not cover Invisalign. Medicaid coverage is limited to metal braces only. Metal braces are typically the cheapest option when it comes to orthodontic care. Most health insurance plans or dental insurance plans (even private plans) provide lower benefits for Invisalign and other cosmetically appealing options.
Metal dental braces might not be the most aesthetically appealing option for some people, but those are the only braces that will usually be covered by Medicaid. Some private or group healthcare coverage might still provide benefits for Invisalign or clear braces. However, Medicaid will typically not provide any coverage for those devices. So, if you opt for something other than metal braces, you might be stuck paying the entire cost on your own.
Medicaid Coverage Of Other Dental Services
So, what does the Medicaid insurance program cover when it comes to other dental benefits? Again, the answer might depend on your age. For children under the age of 21, Medicaid provides dental benefits in every state. This includes regular cleanings, x-rays, checkups, fillings, and other dental services. It even includes orthodontic services when medically necessary. The Medicaid dental program is part of the EPSDT program that provides these and other services to children across the country.
For adults, dental services are only provided in states that include this coverage as part of their Medicaid program. Many states provide no dental coverage at all for adults. This means that you will either need to pay out-of-pocket for dental services or enroll in standalone dental coverage. Since Medicaid receives part of its funding from the state government, each state gets to set its own rules when it comes to Medicaid coverage details.
Other Options To Pay For Braces
So, if Medicaid won’t pay for your braces, what other options do you have for payment? First, you should know that Medicare is not usually an option either—even for those with disabilities. Original Medicare does not provide any dental benefits, and that also applies to orthodontic care. Remember that there are big differences between Medicare and Medicaid. Medicare is available for seniors and people with disabilities, while Medicaid provides health coverage for low-income families.
One option that many people use to help pay for braces is a payment plan. You can ask your orthodontist about any payment plans they may offer to help you spread out the cost of your braces. Many offices will offer a free consultation where they can discuss your treatment options as well as the types of payment plans they offer.
Another option for getting affordable braces is to visit a dental school near you. Students in dental school often need to perform certain procedures, and many dental schools allow people to utilize these services at little or no cost. This could be a great way to get braces at an affordable rate.
Finally, you could apply for free braces through a private organization or non-profit whose mission is to help those who cannot afford them on their own. Many organizations, such as Smiles Change Lives, allow you to apply for free braces through their program. They use donations to help people pay for braces. Some programs are limited to children, while others may also include adults. There is no guarantee that your application will be approved, but these programs help many people afford braces who might not otherwise be able to get them.
The Bottom Line
Whether or not Medicaid will cover braces mainly depends on your age and whether or not the braces are medically necessary. In all states, Medicaid will cover medically necessary braces for children. However, getting braces covered for an adult is more difficult. Only a few states offer Medicaid coverage for braces at all, and you must have a severe condition that requires them. If Medicaid does not cover your braces, you do have a few other options for payment, such as private insurance or a payment plan through your orthodontist.
Frequently Asked Questions
How much do braces cost?
The average cost of braces is around $5,000 to $6,000. The length of treatment you require and the specific type of braces that you need will have an effect on the cost. Clear braces, ceramic braces, and Invisalign are usually more expensive. If you require other orthodontic procedures as part of your treatment, then the cost will increase as well. Most private insurance plans will cover a portion of these charges, and you might be able to get the cost fully covered by Medicaid in some situations.
Can braces be covered by my dental insurance?
Yes, most dental insurance plans provide some coverage for braces. Although the cost is not likely to be covered at 100%, your dental insurance will probably pay for a large portion of the expense. This can greatly help with the cost of braces. You should also know that most dental plans have a lifetime limit on expenses related to orthodontic care. This means that once you have used your full benefit, your plan will not pay for any more orthodontic treatment for you.
What is a medically necessary reason for needing braces?
An orthodontist or dentist will typically decide whether braces are medically necessary. It usually means that you have a medical condition that requires treatment through the use of braces. Simply getting braces for cosmetic reasons, like the straightening of teeth, is not enough to meet the definition. Some medically necessary reasons include TMJ, cleft palate, severe overbite, severe underbite, and others. If your child has a medically necessary reason for braces, then Medicaid will cover them. As an adult, getting Medicaid to pay for your braces is much more challenging. Only a few states offer coverage, and even in those states, your condition must be severe enough to warrant the need for braces.
