Does Medicaid cover braces?
Those eligible for Medicaid may struggle to access orthodontic services like braces which can cost thousands of dollars if paid for out of pocket.
The question of whether or not those on Medicaid can get braces depends on their age, where they live, and medical necessity. In all fifty states Medicaid does cover braces if they are considered "medically necessary."
But what does this mean exactly?
In general terms it means that Medicaid will not pay for braces for members who wish to get them to correct cosmetic issues. Some medical conditions that would allow for braces, in some cases, include excessive overjet, a cleft palate, or overbites and cross bites.
According to Growing Family Benefits, those on Medicaid can get braces covered if they are medically necessary, like if an individual has a "deformity that affects their oral health and or interferes with chewing or speech."
In an effort to define exactly what Medicaid was required to cover when it came to orthodontics, in 2019 the American Association of Orthodontists asked the federal government what it meant by "medically necessary."
However, states still have a fair amount of leeway in how they determine if braces will be covered under Medicaid. Some professionals believe that a good first step would be to contact an orthodontist in your area, set up a consultation, and have them examine your teeth. The doctor will be able to tell you if braces are medically necessary to verify for Medicaid that the procedure complies with their coverage guidelines.
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Can children get braces through CHIP?
The case for children is much simpler. Under the Child Health Insurance Program (CHIP), insurers must provide coverage for procedures to “prevent disease and promote oral health, [and] restore oral structures to health and function.” This means that braces for cosmetic reasons do not need be covered. According to Diamond Braces, only between five and fifteen of cases end up being a medical necessity. In the chance they do qualify, "Medicaid or CHIP will fully cover the cost for treatment, including x-rays, imaging, office visits, the appliance, and follow-up care and retainers.
How much do braces for children with CHIP cost?
For children, the price for metal or gold braces, can range anywhere between $3,000 to $7,300, with the possibility of being reimbursed up to $1,800 - $2,400. Those interested in purchasing invisalign or other orthodontic treatments should not expect to be reimbursed.
Is basic dental coverage included in Medicaid?
Not always. Though many states were allocated funding necessary to provide basic dental care as a part of Medicaid under the American Rescue Plan, not all states accepted the money. In 2021, forty-six provide coverage for dental services in some capacity.
For those looking for affordable dental care, the website Need Help Paying Bills has compiled lists of free dental includes in most states and could be a good place to begin your search.