Medicaid for Braces

What is Medicaid?

Medicaid is a state and federally funded program that offers affordable health coverage to eligible adults, children, pregnant women, elderly adults, and people with disabilities. It’s an assistance program for healthcare to low-income families and individuals who may not be able to afford healthcare.

Does Medicaid Cover Braces?

Medicaid provides comprehensive dental services in most states, but only about 5-10% of these patients are eligible to use their benefits for braces.

Dental benefits include treatment for pain and infections, teeth restoration treatments, and regular check-ups and cleanings.

Unfortunately, in Missouri and most other states, braces are not covered by Medicaid unless they are found to be medically necessary. For children who need braces but do not have a strict medical reason, there is no coverage.

Only a few orthodontic services are covered by Medicaid, including cases of a cleft palate or severe anomalies of the face. If someone is believed to have a condition that needs orthodontic treatment, their dentist would usually refer the patient to a qualified orthodontist for examination to see if the treatment might be approved by Medicaid.

Some pre-orthodontic care is usually covered, including extractions and restorations. A dentist would provide these services.

However, just because a patient may have moderate or severe orthodontic issues — or a dental professional has advised that they need braces — this does not mean that the patient will qualify for coverage.

Other Requirements for Medicaid Coverage

Per the State Orthodontic Consultant (reference Section 13.44 of the Dental Provider Manual) in Missouri, to be eligible for orthodontic services, a patient must meet all the following criteria.

The standard requirements for Medicaid are to be under 21 years of age, have good oral hygiene documented in the child’s treatment plan, and have all dental work completed.

Scenarios of Medicaid likely covering orthodontic treatment include:

• The patient has a cleft palate, severe traumatic deviations, or an impacted maxillary central incisor.
• Speech impediments from tooth and jaw issues.
• The patient has a deep overbite when the lower incisors damage the soft tissue of the palate.
• The orthodontic provider has provided written documentation that proves that orthodontic treatment is medically necessary.
• The patient has an over-jet (teeth positioned horizontally rather than vertically) greater than 9 mm, or a reverse over-jet of greater than 3.5 mm.

Evidence would also include detailed data about a medical condition directly affected by the condition of the mouth or jaw. Braces would be necessary if, without treatment, the condition would result in:

• pain,
• infection,
• illness, or
• significant and immediate impact on the normal function of the body and the patient’s inability to function normally.

Orthodontic Treatment Not Deemed Medically Necessary

• Braces are for aesthetic reasons only.
• Treatment is to correct crowded teeth.
• The patient has demonstrated a lack of motivation to maintain standards of oral hygiene, and oral hygiene is deficient.

Orthodontists Providing Medicaid Services MUST be Missouri Healthnet Providers. Love Orthodontics is not a Medicaid provider.

You can find an approved provider via the Provider Enrollment Unit at mmac.providerenrollment@dss.mo.gov. The American Association of Orthodontists also provides a link if you believe your need for orthodontics is medically necessary.