Medicaid provides dental services including check-ups, cleanings, fillings and extractions. It even covers treatment for pain and infections. In fact, for children under the age of 21, dental check-ups are mandatory. It’s known as the Early and Periodic Screening, Diagnostic and Treatment benefit (EPSDT) and is part of Medicaid’s comprehensive child health program.
States provide dental care for covered children under the Children’s Health Insurance Program (CHIP) but can opt-out of offering coverage to adults. In 32 states, full dental coverage is available, while another 18 states provide dental care to adults only in the case of emergencies. The question is — does Medicaid cover braces? First, let’s find out exactly what Medicaid is.
What is Medicaid?
Medicaid is government-sponsored health insurance. It provides healthcare access to low-income individuals and families. While funding flows from federal and state governments, the program is administered by the states. Medicaid is available for little or no expense to:
- Pregnant women
- People with disabilities
- The elderly
- Low-income and indigent adults
Because Medicaid is administered at the state level, eligibility and benefits vary from state to state.
Medicaid was established in 1965, at the same time as Medicare. In fact, the 2 programs were signed into law almost simultaneously. As part of the Social Security Act, Medicaid was originally intended to provide health services for those who qualified for cash assistance. It has grown from there.
Although many people get them mixed up, Medicaid and Medicare are not the same. While they’re both government-run health insurance, they have major differences. Medicare is health insurance for people 65 and older. To qualify for Medicare, you must first contribute to the system for 10 years or more. Medicare is more like a healthcare retirement system, while Medicaid is insurance for people in poverty with no or low income.
Both cover similar demographics, like the disabled, but Medicaid picks up where Medicare leaves off. Medicaid provides coverage for nursing home care and personal care services. Medicare does not. Medicaid covers people of all ages as long as they fall within certain income eligibility guidelines. Children, too.
Currently, Medicaid is the largest healthcare provider in the United States, covering more than 74 million people or 23% of all Americans. It also pays for half of all births. Medicaid is overseen by the Department of Health and Human Services. But does it cover braces?
Does Medicaid Cover Braces?
The answer is yes. Sort of. Medicaid does cover braces, but only when deemed a medical necessity. What is the definition of a medical necessity? The few orthodontic services covered by Medicare are cleft palates and severe anomalies of the face. Even if the orthodontist recommends Medicaid cover a procedure, it still needs government approval. Since Medicaid differs state by state, decisions on what is covered may vary. Take for example Missouri. Orthodontics is likely covered in cases of:
- Cleft palate
- Speech impediments
- Deep overbite
- Severe crossbite
- Teeth impaction
Conversely, in Florida, children under the age of 21 qualify if they have a handicapping malocclusion. New York also provides braces for kids under 21 with a handicapping malocclusion, although Georgia and Texas do not. In North Carolina, kids with a functional malocclusion qualify. The list goes on. In most states, however, unless there is a clear medical necessity, Medicaid won’t cover braces.
Back in 1965 when Medicaid was first signed into law, the American Dental Association (ADA) worked hand in hand with the federal government in establishing which dental procedures should qualify. The American Association of Orthodontists followed suit, determining that only in cases of medical necessity would Medicaid pay for braces.
Because the states pay for 50% of Medicaid, they have a say what qualifies for coverage and what does not. Although subtle differences in coverage exist from state to state, in general they are in agreement on whether or not to pay for braces.
If you’d like to find out about your state, the Center for Health Care Strategies (CHCS) has broken down dental coverage state by state. Find out about your state’s dental benefits at CHCS.org.
Will Medicaid Cover Braces for Adults?
Medicaid is for the most part insurance for kids 21 and under. In recent years, it has expanded to cover low-income or indigent adults, the disabled and pregnant women. In the case of braces, however, it’s extremely uncommon that an adult will qualify.
In rare cases, Medicaid covers braces, such as when illnesses affect the jaw and neck and make repositioning the teeth necessary, like in cases of:
- Temporomandibular joint disorders (TMJ or TMD)
- Sleep apnea
- Handicapping malocclusions
Again, the reason for braces must be medical. If Medicaid doesn’t cover braces, private options like dental insurance, cash discounts and tax-exempt savings accounts can help.
If you’re on Medicaid, chances are money is tight. The good news is that dental insurance isn’t all that expensive. Unlike medical insurance, dental insurance is affordable. Considering that braces can cost anywhere from $3,000 to $7,000, if you have dental insurance your policy may cover as much as 25% of the cost, or in this case around $1,500. It’s not free, but there are ways to save money.
What if Treatment is not Medically Necessary?
If your treatment is not deemed a medical necessity by Medicaid, you won’t qualify for coverage. Braces for cosmetic reasons do not qualify. If you need braces but Medicaid won’t pay for them, there are private options.
- Dental insurance can be affordable and offers plans that cover braces. Insurance plans that include braces usually pay at a rate of 25% to 50%.
- Going to an orthodontic school clinic for braces may sound harrowing at first, but in reality the students are already licensed dentists completing their orthodontic training. Getting your braces from an orthodontic school can save you a lot of money.
- Working out a payment plan always makes good financial sense. Most dentists offer some type of payment plan to their customers. They are in the business of practicing good health, after all.
- If you’re short on cash but your credit’s okay, think about financing your braces. Many dentists do the financing themselves and require just 50% down.
- Dental assistance programs help low-income families. Free clinics and charitable organizations often have programs. Never underestimate the power of good research.
Another thing to consider is whether or not you really even need braces. These days, alternatives like retainers, head gear, clear aligners and ceramic veneers can work well. At-home aligners are a cost-effective alternative to braces. Not only do you save on the materials, mail-order impression kits save you expensive office visits as well.
Because every state has different needs, they reserve the right to serve their constituents in the best way they see fit. Some states seek alternative benefit plan coverage instead of following the traditional Medicaid guidelines.
Key requirements include:
- Renaming it the Alternative Benefit Plan (ABP)
- Covering the 10 Essential Health Benefits
- Ensuring that individuals receive benefits through ABP
States reserve the right to decide on eligibility.
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Medicaid Is not the Best Program for Braces
Most people consider getting braces because their kids’ teeth are not coming in straight. Cases of medical necessity in orthodontics are the exception, not the rule. It’s a good idea, therefore, not to count on Medicaid to pay for braces.
The only time Medicaid pays for braces are those times that come unexpectedly. Emergencies. Medical necessities. If you have kids, even if times are tough and you seek all the healthcare assistance you can get, you may want to plan for the possibility that they’re going to need braces.
Frequently Asked Questions
What deems it medically necessary for braces?
Medicaid does not pay for braces unless there is a medical necessity. What qualifies as a necessity? Both a handicapping malocclusion and a handicapping dentofacial deformity are health hazards that can adversely affect speech and are therefore deemed medical necessities.
In cases where the condition of the teeth can negatively affect the well-being of the patient overall, a medical-necessity determination qualifies. Crooked or impacted teeth do not necessarily constitute a medical necessity. In cases where the deformities are uniquely cosmetic, Medicaid does not provide coverage.
Are braces covered by Medicaid?
In general, Medicaid doesn’t cover braces. There are exceptions, like medical necessities, but for cosmetic purposes, Medicaid does not pay for braces. Braces are typically approved only for children 21 years and younger, although in some cases, where the health of the patient is in jeopardy, adults are also covered.
Medicaid and Medicare are very similar programs. While Medicare covers people 65 or over, Medicaid is health insurance for those in financial need. Neither, however, provides orthodontic care, except in case of emergency
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