Does Medicaid Pay for Children’s Braces?

Medicaid is a joint federal and state program providing health coverage to eligible low-income individuals and families. This public health insurance program covers healthcare expenses, including dental and orthodontic needs for children. The program is financed by both federal and state governments, with states administering their own programs within federal guidelines.

Medicaid Coverage for Braces

Medicaid coverage for children’s braces depends on whether the treatment is deemed “medically necessary.” This determination distinguishes between functional problems and cosmetic concerns. Conditions like severe malocclusion, significant functional impairments, speech issues, difficulty eating, or pain may qualify for coverage. Cosmetic alignment of teeth alone is not covered.

A federal mandate, the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit, ensures comprehensive healthcare services for Medicaid-enrolled children under age 21. This benefit mandates that states cover all medically necessary services to correct or ameliorate health conditions, including dental care and orthodontic services. Criteria for medical necessity in orthodontics can vary by state. Families should consult their state’s Medicaid guidelines for details on coverage.

Medicaid Eligibility for Children

Eligibility for Medicaid is determined by household income, household size, and residency. Each state sets its own income thresholds and criteria within federal guidelines. For children, eligibility extends to families with incomes at or below a certain percentage of the Federal Poverty Level (FPL).

Federal law requires states to cover children up to at least 133% of the FPL, but many states cover children at higher income levels, sometimes exceeding 200% or 300% of the FPL. Applicants must be residents of the state and U.S. citizens or qualified non-citizens. Information on income limits and eligibility criteria is available on state Medicaid websites or through local social services offices.

The Application and Approval Process

Applying for Medicaid involves submitting documentation to verify household income, residency, citizenship or immigration status, and household composition. Documents include pay stubs, tax returns, utility bills, birth certificates, and Social Security numbers. Applications can be completed online, by mail, or in person. Once Medicaid eligibility is established, a separate process is required to obtain approval for children’s braces.

This approval involves a prior authorization process. A general dentist usually provides a referral to an orthodontist, who conducts a comprehensive examination. The orthodontist gathers diagnostic records, such as X-rays, dental models, and photographs, and develops a proposed treatment plan. This information, with justification for medical necessity, is submitted to Medicaid for review. Medicaid examiners assess the request and notify the family and orthodontist of approval or denial, which can take several weeks to months.

Locating Orthodontic Providers

Finding an orthodontist who accepts Medicaid requires specific search strategies. Many state Medicaid programs offer online provider search tools on their official websites to locate participating practices. These directories can be filtered by specialty and location. Families can also contact their child’s general dentist for referrals to orthodontists within the Medicaid network.

Local health clinics or community dental centers often have lists of specialists who accept Medicaid. Confirm that an orthodontic office accepts Medicaid before scheduling appointments, as not all practices participate. Online platforms may also help identify orthodontists by insurance carrier.