Braces can be expensive and difficult for many to afford without insurance coverage. Even with insurance, the cost of braces can strain many budgets.
Whether Medicaid covers braces will depend largely on the state in which you live. Though there are certain mandatory benefits that each state Medicaid program must cover, dental care is an example of an optional Medicaid benefit that may not be covered in all states.
All state Medicaid programs must cover routine cleanings and checkups, teeth restoration, relief from pain and infection and medically necessary orthodontic services for those under the age of 21 in households enrolled in Medicaid. This basic set of dental benefits is called Early and Periodic Screening, Diagnostic and Treatment (EPSDT).
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When it comes to whether Medicaid will cover braces for those under 21, the key is “medically necessary” orthodontic services. Each state may have its own definition of “medically necessary,” so qualifying for coverage may not be consistent from one state to the next.
Below is an example of some of the things that may be required in order for a set of braces to be deemed medically necessary and therefore covered by Medicaid.
This list is only an example, and each state may have its own set of requirements for how it defines “medically necessary.” Additionally, Medicaid treats each person seeking braces on a case-by-case basis so there may be some subjectivity even within each state.
In addition to the minimum standards required of each state, some states grant even more coverage for braces and other orthodontic services or have more lenient qualification requirements.
Whether or not your child under the age of 21 qualifies for Medicaid coverage for braces ultimately depends on the state in which you live. You can view a directory of state Medicaid programs and contact your state’s program to inquire about dental and braces coverage for your child.
There are no federal mandates requiring state Medicaid programs to provide dental coverage to adults ages 21 and over. Whether or not Medicaid offers dental coverage, including braces, is entirely up to each state.
In most states, Medicaid at least covers emergency dental care for adults, but coverage of routine dental care for adults isn’t as common. Even more rare is coverage of braces and other orthodontic services. Braces may be covered when needed to treat a broken jaw or other injury or an illness that affects the jaw. But Medicaid’s coverage of braces in adults is much more restrictive than for those under 21.
If you are eligible for both Medicaid and Medicare, you might be able to obtain coverage for braces through a Dual-eligible Special Needs Plan (D-SNP). This is a type of Medicare Advantage plan that is built specifically for beneficiaries who are eligible for both Medicare and Medicaid.
If you are eligible for both Medicare and Medicaid, contact a licensed insurance agent to learn more about Dual-eligible Special Needs Plans and find out if any such plans are available for enrollment in your area.
Speak with a licensed insurance agent
Christian Worstell is a senior Medicare and health insurance writer with MedicareAdvantage.com. He is also a licensed health insurance agent. Christian is well-known in the insurance industry for the thousands of educational articles he’s written, helping Americans better understand their health insurance and Medicare coverage.
Christian’s work as a Medicare expert has appeared in several top-tier and trade news outlets including Forbes, MarketWatch, WebMD and Yahoo! Finance.
Christian has written hundreds of articles for MedicareAvantage.com that teach Medicare beneficiaries the best practices for navigating Medicare. His articles are read by thousands of older Americans each month. By better understanding their health care coverage, readers may hopefully learn how to limit their out-of-pocket Medicare spending and access quality medical care.
Christian’s passion for his role stems from his desire to make a difference in the senior community. He strongly believes that the more beneficiaries know about their Medicare coverage, the better their overall health and wellness is as a result.
A current resident of Raleigh, Christian is a graduate of Shippensburg University with a bachelor’s degree in journalism.
If you’re a member of the media looking to connect with Christian, please don’t hesitate to email our public relations team at Mike@tzhealthmedia.com.