When Does Medicaid Cover Orthodontics?

Insurance will typically cover orthodontic treatment if there is a medical necessity for it, for example, a functional issue created by teeth or bite misalignment. Insurance does not cover orthodontic treatment if done purely for cosmetic concerns.

Coverage varies between insurance plans. Below I have highlighted Medicaid’s qualifications for orthodontic coverage.

What is Medicaid

Medicaid is a joint federal and state program that helps cover medical costs for certain low-income people. Dental coverage via Medicaid varies from state to state, as each state runs its own program.

You can find out if you qualify for your state’s Medicaid program at Medicaid.gov.

Medicaid’s Orthodontic Coverage

Age Limit

Medicaid aims for early intervention and preventative treatment, so coverage is limited to patients under the age of 21. For adults above the age of 21, Medicaid may still cover orthodontic treatment (depending on the state) if it is shown that this is the most efficient and cost-effective way of addressing a medical health concern.

What is Considered Medically Necessary?

Unfortunately, it is up to the states to decide what exactly falls under “medically necessary,” so this may vary from state to state.

The American Association of Orthodontics (AAO) defined “medically neccessary” as such:

“Orthodontic services to prevent, diagnose, minimize, alleviate, correct, or resolve a malocclusion (including craniofacial abnormalities and traumatic or pathologic anatomical deviations) that cause pain or suffering, physical deformity, significant malfunction, aggravates a condition, or results in further injury or infirmity.”

The AAO also proposed these “auto-qualifiers” in an attempt to better streamline what is considered medically necessary.

• Overjet: 9 mm or more.

• Reverse overjet: 3.5 mm or more.

• Anterior and/or posterior crossbite of 3 or more teeth per arch.

• Lateral or anterior open bite: 2 mm or more; of 4 or more teeth per arch.

• Impinging overbite with evidence of occlusal contact into the opposing soft tissue.

• Impactions where eruption is impeded but extraction is not indicated (excluding third molars).

• Jaws and/or dentition which are profoundly affected by a congenital or developmental disorder (craniofacial anomalies), trauma or pathology.

• Congenitally missing teeth (excluding third molars) of at least one tooth per quadrant.

• Crowding or spacing of 10 mm or more, in either the maxillary or mandibular arch (excluding 3rd molars).

It’s easy to get bogged down in these dental terms and numbers, so the best course of action is to go to your orthodontist and have them evaluate if you qualify for orthodontic coverage in your state.

How to Find Out if You’re Covered

Most Orthodontists offer free consultations, so book an appointment with an orthodontist that accepts and is familiar with Medicaid. At the consultation, they will do a full orthodontic evaluation and determine if treatment is medically necessary. If it is determined to be medically necessary, they then submit the necessary documents and records for Medicaid approval. Your state Medicaid program will review those and inform you and the orthodontist if it was accepted.

Variations Between States

Medicaid coverage varies from state to state.

• Federal regulations require states to cover medically necessary orthodontics for patients with Medicaid under the age of 21. However, states have varying coverage for adults above the age of 21. Even if deemed medically necessary, some states may not cover orthodontic treatment for adults.

• States can determine which services exactly are covered, so even if you do get Medicaid coverage, there could still be some out-of-pocket costs depending on what your state’s Medicaid will cover.

• Alternative, but more expensive, options to braces may or may not be covered depending on the state. For example, some states do not consider Invisalign (clear plastic aligners) to be a medically necessary treatment and thus won’t cover it.

• State’s may define “medically necessary” differently.

Check your state Medicaid program’s website or call them to get the most up-to-date information.

Variations Between Orthodontists

Not all orthodontists accept Medicaid, so be sure to do your research and contact different offices to see if they do. One helpful resource is Zocdoc.com, on which you can put in your location and insurance and it will pull up several in-network providers.

What if I Don’t Qualify for Medicaid?

For low-income children under 19 years old who do not qualify for Medicaid but cannot afford private insurance, the Children's Health Insurance Program (CHIP) can be a helpful alternative. CHIP, similarly to Medicaid, only covers orthodontic treatment if deemed medically necessary.