Does Medicaid cover braces?
The answer depends on your age, the state where you live, and the reason you need to straighten your teeth.
This public benefit program provides essential but not comprehensive dental care in most states, and orthodontists’ work often falls into a gray area.
Adults hoping to have Medicaid pay for Invisalign will often strike out – unless a covered accident or illness drives the need to reposition your teeth using metal appliances.
Meanwhile, low-income families with children can take advantage of orthodontic coverage more frequently because laxer standards often apply.
Braces Cost With Medicaid
If covered, the cost of dental braces with Medicaid depends on the type of appliance you choose and whether your orthodontist participates in your plan.
Braces Choice
Your choice of appliance determines the cost of orthodontic braces with Medicaid, as this publically funded program only pays for the least expensive treatment alternative.
Free braces programs for low-income families hinge on Medicaid reimbursement for the least expensive treatment. If you pick a pricier alternative, you might be responsible for the balance, which most low-income families cannot afford and administrators are unlikely to approve.
Cost Range After Estimated $2,000 Reimbursement
| Type | Average Price | Your Cost |
| Metal | $2,000 to $7,000 | $0 to $5,000 |
| Gold | $3,200 to $7,300 | $1,200 to $5,300 |
| Invisalign | $3,400 to $7,100 | $1,400 to $5,100 |
| Ceramic | $4,000 to $8,000 | $2,000 to $6,000 |
| Lingual | $8,000 to $10,000 | $6,000 to $8,000 |
Participating Orthodontists
The location of your orthodontist influences how much dental braces cost with Medicaid. Many recipient patients must travel to inconvenient offices, incurring additional transportation expenses.
Nearby orthodontists who take Medicaid are often challenging to find because of the meager reimbursement rates. Participating offices must accept the below-market allowed amount as full payment, so many decline these patients.
Include travel expenses for nine to twelve annual visits in your total cost estimate. You must see your orthodontist periodically for evaluation, installation, adjustments, repairs, removal, and retainers.
Medicaid Invisalign Coverage
Many recipients ask several questions about Medicaid and Invisalign, suggesting much confusion. We do our best to address coverage, Managed Care Organizations, and acceptance of the allowed amount.
Benefits
Medicaid rarely covers the total cost of Invisalign for adults or children because it is typically not the least expensive treatment alternative. Invisalign commands a premium price for cosmetic reasons; clear trays look better than metal braces.
You must show Invisalign is medically necessary before Medicaid would pay the entire cost. In other words, only clear trays could treat your condition, not metal braces: a long shot.
Accepting
Invisalign does not accept Medicaid because the company markets and manufactures the clear trays (Align Technology), which are distributed through orthodontists and do not sell directly to the public.
You must find an Invisalign-trained orthodontist who accepts Medicaid reimbursement as total payment, which narrows the field considerably. However, most low-income families cannot afford the incremental costs.
Fidelis
Recipients also ask whether a specific Managed Care Organization (MCO), such as Fidelis, covers Invisalign. An MCO is a private third-party company that administers Medicaid claims in designated states.
Each MCO follows underwriting rules determined by the states. Therefore, the coverage requirements for Invisalign are no different for these six largest claims administrators.
- Centene (Fidelis)
- Anthem/BCBS
- United Healthcare
- Amerigroup
- Wellcare
- Molina
Medicaid Adult Braces
The answer to whether Medicaid covers orthodontic braces for adults hinges on the age of majority defined by your state and the reason the patient needs to straighten their teeth.
Adults Over 21
With a narrow medically necessary definition, Medicaid sometimes covers dental braces for adults over twenty-one under its health insurance umbrella; orthodontia prevents, diagnoses, or treats an injury, disease, or its symptoms.
Getting health insurance to cover dental braces requires a medical diagnosis from a licensed physician who prescribes orthodontia to treat your condition rather than surgery or medications.
For example, Medicaid might pay for adult braces prescribed by a doctor to correct one of these injuries or diseases.
- Reposition teeth after a non-biting accident such as a broken jaw
- Temporomandibular Joint Disorders (TMJ or TMD) bite adjustments
- Sleep apnea (when crooked teeth restrict or block airflow)
Adults Under 21
Medicaid often pays for braces for adults under twenty-one, giving many recipients a three-year window to complete treatment after turning eighteen.
Each state determines the age of adulthood when it stops honoring claims for orthodontic services under the dental insurance umbrella of the program. The qualifying criteria are far more lenient, as you will soon learn.
| Age Limit | Number of States |
| 21 | 42 |
| 20 | 4 |
| 18 | 2 |
| 16 | 1 |
Medicaid Braces for Kids
Medicaid covers braces for children more frequently because three more lenient standards might make recipients eligible. You become an adult at age eighteen, giving up to three years to capitalize.
Congenital Defects
Medicaid sometimes covers dental braces for kids under the health insurance element of the program using an expanded definition for medically necessary treatment.
Your child could qualify for reimbursement if they were born with a congenital disability that requires correction via orthodontia.
- Cleft Lip and or Cleft Palate
- Crouzon Syndrome/Craniofacial Dysostosis
- Hemifacial Hypertrophy/Congenital Hemifacial Hyperplasia
- Parry-Romberg Syndrome/Progressive Hemifacial Atrophy
- Pierre-Robin Sequence/Complex
- Treacher-Collins Syndrome/Mandibulofacial Dysostosis
Medically Necessary
Medicaid will sometimes pay for orthodontic braces for children using a medically necessary definition exclusive to the dental insurance component of the program. These cases represent the most significant level of severity.
The American Association of Orthodontists has proposed automatic qualifiers.
- Overjet equal to or greater than 9mm
- Reverse overjet equal to or greater than 3.5mm
- Posterior crossbite with no functional occlusal contact
- Lateral or anterior open bite equal to or greater than 4mm
- Impinging overbite with either palatal trauma or mandibular anterior gingival trauma
- One or more impacted teeth with an eruption that is impeded (excluding third molars)
Point System
Medicaid frequently covers braces for children under the dental insurance component. It uses an index or point scoring system to quantify the level of handicapping malocclusion. Qualifying patients must register a score above a specific threshold.
Your local orthodontist should be familiar with the method used in your state and help you assemble the documentation needed to support a claim.
- Plastic study models of teeth
- Cephalogram: X-rays of the jaw
- Panoramic radiograph of the mouth
- Intraoral photographs
| Point System | States Using |
|---|---|
| Handicapping Labio-Lingual Deviation | Arkansas, Alaska, California, Massachusetts, Minnesota, Montana, New Mexico, New York, Texas |
| Salzmann Index | Connecticut, Wisconsin, Utah, South Dakota, Iowa |
