Does CHIP Cover Braces in Texas?

The Children’s Health Insurance Program (CHIP) in Texas provides health coverage for children in families who earn too much money to qualify for Medicaid but cannot afford private insurance. CHIP in Texas covers orthodontic services, including braces, only when medically necessary for severe conditions, not for cosmetic reasons.

CHIP Eligibility in Texas

For a child to qualify for CHIP in Texas, several requirements must be met, primarily revolving around income and residency. Eligibility is determined by comparing a family’s income to the Federal Poverty Level (FPL), with specific income limits varying based on household size. Generally, children in families earning up to 201% of the FPL may be eligible for CHIP, while those between 151% and 186% of the FPL might have different cost-sharing requirements than those at or below 151% FPL.

Additionally, the child must be under 19 years of age and a resident of Texas. Children must also be U.S. citizens or qualified non-citizens. A child is typically ineligible if they are already covered by other health insurance, though there can be exceptions.

Orthodontic Coverage Criteria for Texas CHIP

This coverage is typically considered a medical plan benefit rather than a standard dental benefit. Prior authorization is always required before any orthodontic treatment can begin.

The medical necessity for braces under Texas CHIP is generally limited to pre-surgical or post-surgical orthodontic services for specific craniofacial anomalies. This includes conditions such as cleft lip and/or palate, severe traumatic, skeletal, or congenital craniofacial deviations, and severe facial asymmetry resulting from skeletal defects, congenital syndromal conditions, or tumor growth and its treatment.

Accessing CHIP and Orthodontic Services

Applying for CHIP in Texas can be done through various methods, including an online portal, by phone, or in person. Families will need to provide information about their household income, residency, and the children needing coverage. Once the application is submitted, the Texas Health and Human Services Commission reviews it to determine eligibility based on the established criteria.

After CHIP coverage is established, securing medically necessary orthodontic services involves a specific process. The child’s primary care provider or dentist will typically need to assess the condition and provide a referral to an orthodontist. The orthodontist will then conduct their own assessment and gather documentation to demonstrate that the condition meets the strict medical necessity criteria set by CHIP. This documentation, along with a proposed treatment plan, is submitted to the managed care organization overseeing the child’s CHIP benefits for review and prior authorization.