The Ins and Outs of Braces Coverage Under Medicaid

Did you know that 80.4 million people are currently covered by Medicaid? Despite the huge percentage of people currently on Medicaid, there’s no denying that there are still some serious gaps in coverage.

And, nowhere is this more apparent than Medicaid coverage for braces. So, does Medicaid cover braces for adults? And what about children?

If you want to learn the answer to these questions, and more, then you’re in the right place. In this guide, we’ll teach you everything you need to know about Medicaid braces coverage.

Does Medicaid Cover Braces for Children?

Children typically have a much better chance of getting braces under Medicaid than adults do. This is thanks to the Child Health Insurance Program (or CHIP).

CHIP is available for children enrolled in Medicaid and it provides additional dental benefits. Specifically, for things like dental cleanings, restorations, check-ups, and pain medication.

But, what about braces? Under the CHIP program, insurers must provide coverage for procedures that do the following:

  • Prevent diseases from occurring
  • Promote overall dental health
  • Restore health and function to oral structures

Under this classification, there are a lot of conditions that might require a child to get braces. Ultimately, it all comes down to what the physician recommends and what state you’re living in.

We will say that if it interferes with how the child’s mouth operates when they chew and swallow, then you have a good chance of getting Medicaid protection.

This can include conditions like jaw problems, cleft palates and lips, congenital defects, missing teeth from a genetic condition, overjet protrusions, and overbites/underbites that are severe.

Does Medicaid Cover Braces for Adults?

Unfortunately, it’s much harder to get Medicaid orthodontic coverage for adults than it is for kids. That’s because Medicaid will only cover adults if it’s deemed medically necessary.

What’s deemed a medical necessity? Here are some examples of reasons Medicaid has provided coverage for braces in the past:

  • Dislodged teeth
  • Broken jaws
  • Temporomandibular joint disorders or TMD
  • Handicapping Malocclusions
  • Sleep Apnea
  • Other jaw and neck ailments

Remember that it ultimately depends on whether or not your physician believes that it relates to a medical necessity. So, make sure to give as much detail about how it affects your jaw or mouth as possible.

Remember that Medicaid will cover braces if it will fix a condition that affects either the normal routine of your day or your body’s daily function. So, make sure to let your doctor know how it’s affecting this.

In addition, Medicaid has expanded coverage for pregnant people, low-income groups, and disabled communities. So, if you fall in one of these categories, then make sure to check your policy.

What Does Medicaid Not Cover?

We’ve gone over some of the reasons why Medicaid will provide braces coverage. But, what about some of the common reasons why they won’t provide coverage?

The most common reason for not covering braces under Medicaid is cosmetic reasons. If you just want braces to have a more attractive smile, then there’s little to no way you’ll ever get approved.

The same is true of treatments meant to correct any crowded teeth. Finally, the orthodontist has the right to refuse Medicaid coverage if they don’t seem to care about their oral/hygiene standards.

This can be a bit of a nebulous reason. But if your refuse to take care of your teeth besides seeing treatment, then you may be denied.

How Do You Know if You Qualify?

If you’re feeling confused about whether or not you can get braces coverage under Medicaid, then you’re not alone. Medical necessity can a confusing reason for braces, and one that leaves a lot of room for interpretation.

The good news is that many Medicaid-approved orthodontists will allow you to schedule a free consultation. At this meeting, the orthodontist can examine you and decide whether or not your condition calls for Medicaid-covered braces.

If it does meet their qualifications, then they’ll discuss if Medicaid covers all the expenses or just a fraction of them. From there, you can decide on what course of action is best for your budget.

Assuming you still want braces, even if they aren’t covered, they can advise you on your financial options for dealing with the cost of braces.

Does Medicaid Cover Basic Dental Care?

Forty-six states provide basic dental care through Medicaid in some way, shape, or form. Sadly, there are some coverage gaps. That’s because some states refuse to accept money from the American Rescue Plan.

If you live in one of these states, then you might want to look for providers that offer free dental services to certain groups.

Look for a Provider That Works With You

Ideally, you want an orthodontist that accepts your Medicaid insurance. But, more important than that is to find one that works with you.

Remember that whether or not Medicaid will cover your or your child’s procedure depends on their condition. So, you want a professional that’s willing to help you find out whether they’re covered.

More importantly, they should be willing to work with you to find a financial solution regardless of whether you’re covered or not. If you need a provider like this, then visit Weddle Orthodontics here.

Or, you can do a quick local search in your area. Just make sure you read the reviews to get a sense of what the average customer experience was like.

Appreciate Learning About Medicaid Dental Coverage? Keep Reading

We hope this article helped you answer the question, Does Medicaid cover braces for adults? As you can see, the answer depends on specific circumstances, like your age, location, and whether or not the braces are medically necessary.

So, find a provider today to ask if you qualify for Medicaid coverage on your braces. Did you appreciate learning about braces? If you want articles on similar topics, then keep exploring our website for more.


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