How to Get Braces Covered by Medical Insurance

Braces are often perceived as a cosmetic dental treatment, typically covered by dental insurance. While dental plans are the most common source of coverage, medical insurance can sometimes assist with orthodontic treatment. Understanding the roles of medical and dental coverage, particularly medical necessity, is crucial for navigating coverage. Securing medical insurance coverage for braces hinges on understanding policy details and diligent documentation.

Understanding Medical and Dental Coverage

Distinguishing between medical and dental insurance is important when considering orthodontic treatment. Dental insurance typically covers routine care, such as cleanings and fillings, and often includes some benefits for orthodontic treatment, especially for individuals under 18. Coverage usually comes with limitations, such as a lifetime maximum benefit or age restrictions, and may require a separate rider or plan.

Medical insurance, in contrast, focuses on the treatment of illnesses, injuries, and conditions that affect overall health. Braces are generally categorized as a dental procedure, meaning medical insurance rarely covers them if the need is purely cosmetic. However, medical insurance may provide coverage if the orthodontic treatment is deemed “medically necessary,” addressing a health issue beyond just teeth alignment. Dental plans often cover a portion of orthodontic costs for children, but adult orthodontic coverage is less common and frequently more limited.

Establishing Medical Necessity for Braces

Coverage for braces under medical insurance is contingent upon a diagnosis of medical necessity. This means the orthodontic treatment must address a severe condition affecting overall health. Common conditions that may qualify include severe malocclusion (misalignment of teeth and jaws) causing functional impairments. These impairments might manifest as difficulty chewing or speaking, chronic jaw pain, or breathing problems like sleep apnea.

Congenital conditions, such as a cleft palate, also often require orthodontic intervention and are considered medically necessary. Other qualifying issues include severe overbites, underbites, crossbites, or significant crowding that leads to difficulties with oral hygiene, increasing the risk of tooth decay or gum disease. To support a claim of medical necessity, comprehensive documentation is essential. This typically includes detailed reports from an orthodontist and other relevant medical specialists, such as an oral surgeon or ear, nose, and throat doctor. X-rays, photographs, dental charting, and a narrative description outlining the specific functional impairment and how orthodontic treatment will alleviate it are essential evidence.

Navigating the Insurance Process

Once medical necessity has been established and supporting documentation gathered, navigate the insurance process. Begin by thoroughly reviewing your medical insurance policy documents. Look for clauses related to medically necessary orthodontic treatment, and identify any exclusions, limitations, deductibles, or co-insurance requirements.

A crucial step is seeking pre-authorization or pre-determination from your medical insurance company before treatment begins. This process involves submitting the orthodontist’s detailed treatment plan, along with the gathered medical necessity documentation, to the insurer for approval. The insurance company will review these materials to determine if the proposed treatment meets their criteria for coverage. You should expect a response that either approves the treatment, denies it, or requests additional information. Consistent and clear communication with your orthodontist’s office, who can provide necessary billing codes and documentation, and the insurance company is vital during pre-authorization.

Addressing Denials and Exploring Other Options

Despite a strong case for medical necessity, medical insurance coverage may still be denied. If this occurs, carefully review the denial letter to understand the specific reasons provided and note any deadlines for an appeal. The internal appeals process involves submitting a formal written request to the insurance company, often with additional supporting documentation like a second opinion from another specialist or more detailed clinical notes. It is important to adhere strictly to submission instructions and timelines, as some plans may have multiple levels of appeal.

If internal appeals are unsuccessful, some plans offer the option for an external review by an independent third party. If medical insurance coverage is not secured, several alternative financing options can help manage the cost of braces:

• Dental insurance plans with orthodontic benefits can cover a portion of the expense, though coverage varies significantly and often has lifetime maximums.
• Orthodontic offices frequently offer in-house payment plans, allowing the total cost to be paid in installments, often with no interest.
• Flexible Spending Accounts (FSAs) and Health Savings Accounts (HSAs) provide a tax-advantaged way to pay for qualified medical expenses, including orthodontic treatment, using pre-tax dollars.
• Healthcare financing companies like CareCredit.
• Personal loans.
• Programs at dental schools or community clinics that offer reduced costs.