Will Medicaid cover braces and other Orthodontic Treatment for Kids or Adults? What You Need to Know in 2025!

Medicaid, the joint federal and state program, offers health coverage to eligible low-income individuals, including children, pregnant women, elderly adults, and people with disabilities. A common question among beneficiaries is: “Will Medicaid cover braces?” The answer is multifaceted, depending on factors such as medical necessity, age, and state-specific regulations.​

What is Medicaid Insurance

Medicaid insurance is a government-funded health coverage program in the United States that provides free or low-cost medical care to eligible low-income individuals, including children, pregnant women, elderly adults, and people with disabilities. It is jointly funded by the federal and state governments and covers various essential health services.

What Are The Different Types of Medicaid Insurance?

Medicaid is a public health insurance program in the United States designed to provide medical coverage for low-income individuals and families. While it’s a federal program, Medicaid is administered at the state level, which means coverage types and benefits can vary across the country. Understanding the different types of Medicaid insurance helps you choose the right plan for your healthcare needs.

1. Traditional or Fee-for-Service Medicaid

Traditional Medicaid, also called Fee-for-Service (FFS) Medicaid, is the original form of Medicaid. In this model:

• The state pays healthcare providers directly for each service.
• Patients can usually choose any doctor or hospital that accepts Medicaid.
• It’s often used in rural areas or for individuals who need highly specialized care.

However, most states are gradually replacing FFS with managed care to control costs and improve service coordination.

2. Managed Care Medicaid

Managed Care Organizations (MCOs) are now the most common form of Medicaid insurance. In this model:

• The state pays a private insurance company a fixed amount per person enrolled.
• The MCO then handles all healthcare services for the enrollee.
• Patients are typically required to use a network of approved providers.

Benefits of managed care include better coordination of services, preventive care focus, and lower administrative costs. Most children, pregnant women, and low-income adults are enrolled in Medicaid Managed Care.

3. Medicaid Expansion Plans (Under the ACA)

Under the Affordable Care Act (ACA), states had the option to expand Medicaid to more low-income adults. These Medicaid expansion plans cover:

• Adults under 65 years old
• Income up to 138% of the federal poverty level (FPL)
• No requirement to have children or a disability

As of now, most states have adopted Medicaid expansion, although some have not. These plans typically operate through managed care but cover a broader population.

4. Dual Eligible Plans (Medicare-Medicaid Plans)

People who qualify for both Medicare and Medicaid are considered dual eligibles. They may receive:

• Medicare benefits for hospital and doctor visits
• Medicaid benefits for long-term care, copays, and medications

States offer Medicare-Medicaid Plans (MMPs) or Dual Eligible Special Needs Plans (D-SNPs) that combine both services for easier coordination.

5. Children’s Health Insurance Program (CHIP)

Although technically separate from Medicaid, CHIP is often administered alongside Medicaid by state agencies. It provides low-cost health insurance for:

• Children in families with incomes too high for Medicaid but too low for private insurance
• Pregnant women (in some states)

CHIP covers services like dental, vision, and regular check-ups, similar to Medicaid benefits.

6. Medicaid for Long-Term Services and Supports (LTSS)

This type of Medicaid helps individuals with chronic illnesses, disabilities, or seniors who require:

• Nursing home care
• In-home health services
• Assisted living support

LTSS coverage varies by state and often includes waiver programs that let individuals receive care at home rather than in institutions.

Medicaid Coverage Criteria for braces and other Orthodontic Treatment

Orthodontic treatment like braces can be life-changing, but under Medicaid, it’s not automatically covered for everyone. Instead, coverage depends on strict criteria that focus on medical necessity, age eligibility, and state-specific regulations. Let’s break it down in detail:

1. Medical Necessity is the Primary Requirement

Medicaid will only cover orthodontic treatment if it is deemed medically necessary. This means braces are not approved for cosmetic purposes, such as straightening mildly crooked teeth or improving smiles. To qualify, patients must have conditions that significantly affect oral function or health, such as:

• Severe malocclusion (misaligned bite that impairs chewing or speaking)
• Cleft palate or cleft lip
• Overbite, underbite, or crossbite causing pain or functional problems
• Jaw growth issues that affect proper mouth opening or alignment
• Speech impairment due to misaligned teeth

The determination of medical necessity must be made by a Medicaid-enrolled orthodontist, and detailed documentation must be submitted.

2. Age Plays a Critical Role

Medicaid’s orthodontic benefits are more accessible for individuals under 21 years of age, thanks to the EPSDT (Early and Periodic Screening, Diagnostic, and Treatment) mandate. EPSDT requires Medicaid to provide any necessary dental service—even if not typically covered—when needed to correct or improve a health condition in a child.

For adults over 21, orthodontic coverage is extremely limited. Most states do not cover braces for adults, unless the condition is deemed extremely severe and medically debilitating (e.g., jaw surgery cases).

3. Required Documentation for Medicaid Approval

Getting approval from Medicaid for braces involves a thorough documentation process. The following are usually required:

This paperwork must be submitted for prior authorization, and coverage is not guaranteed unless the request is approved.

4. State-by-State Variability in Criteria

Since Medicaid is administered at the state level, coverage guidelines can vary. For example:

• California covers braces for children with moderate to severe orthodontic needs.
• Texas limits braces to specific dental deformities under its CHIP program.
• Florida uses a point system to score the severity of orthodontic needs.
• New York offers generous coverage for children but rarely for adults.

It’s important to contact your state Medicaid office or visit your state’s Medicaid website for specific orthodontic guidelines.

5. Additional Notes on EPSDT and Braces

The EPSDT benefit plays a major role in increasing access to braces for children. Under EPSDT, even if braces aren’t part of your state’s standard Medicaid dental package, they must be provided if a doctor or dentist determines they are necessary for correcting a health problem. This federal mandate ensures that low-income children have access to crucial healthcare services, including orthodontic care.

6. Adult Braces: Exceptions to the Rule

While rare, there are a few cases in which adults may receive Medicaid-covered braces. These typically involve:

• Orthognathic (jaw) surgery preparation
• Congenital anomalies requiring correction
• Injuries due to accidents or trauma affecting the jaw/teeth
• Severe dental and facial deformities

Again, strong justification and extensive documentation are required—and approval is never guaranteed.

7. Medicaid-Approved Orthodontist: A Must

To be eligible for Medicaid coverage, your orthodontist must be enrolled in your state’s Medicaid program. Seeking treatment from a private or out-of-network provider will result in denial of coverage, regardless of your condition’s severity.

Ask your dentist or local health department to recommend Medicaid-participating orthodontists in your area.

8. When Braces Are Not Covered

Even if you or your child need braces, Medicaid may deny coverage if:

• The condition is purely cosmetic
• The dental issue doesn’t meet the minimum severity threshold
• Incomplete or incorrect documentation was submitted
• The provider is not Medicaid-approved
• You reside in a state with minimal adult dental coverage

9. Appeals and Reconsiderations

If Medicaid denies your request for orthodontic treatment, you can:

• Request an appeal or fair hearing
• Submit additional documentation
• Get a second opinion from another Medicaid-approved provider

Many denials are reversed when further evidence is presented, so don’t lose hope if the initial response is negative.

Summary Table: Medicaid Coverage at a Glance

Medicaid coverage for braces isn’t automatic—it’s based on medical necessity, age eligibility, and state guidelines. Children under 21 have the highest chance of approval through EPSDT. Adults face more restrictions, but exceptions exist in extreme cases. Understanding the Medicaid coverage criteria for orthodontic treatment can help you prepare properly, gather the right documents, and explore alternatives if needed.

If you’re wondering, “Will Medicaid cover braces?”—the best place to start is by speaking with a Medicaid-approved orthodontist and checking with your state Medicaid office to learn about your specific eligibility.

Understanding Medicaid’s Dental Coverage

Medicaid’s dental benefits are categorized into two primary groups:​

1. Children (Under 21): Under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit, Medicaid mandates comprehensive dental services for individuals under 21. This includes preventive, diagnostic, and treatment services. If braces are deemed medically necessary, they are typically covered. The EPSDT ensures that any service necessary to address health conditions is provided, even if the service isn’t covered under the state’s Medicaid plan for adults.​
2. Adults (21 and Over): Medicaid’s dental coverage for adults is less comprehensive and varies by state. While some states offer extensive dental benefits, others may provide limited or emergency-only services. Orthodontic treatments like braces for adults are less commonly covered and are typically approved only in cases of extreme medical necessity.​

Defining Medical Necessity for Braces and Other Orthodontic Treatment

For Medicaid to cover braces, the treatment must be considered medically necessary. This determination varies by state but generally includes conditions that significantly affect oral health and daily functioning. Examples include-

• Severe Malocclusion: Misalignments that impede normal chewing or speaking.​
• Cleft Palate or Lip: Congenital deformities affecting the mouth’s structure.​
• Jaw Irregularities: Issues causing difficulty in opening or closing the mouth.​
• Extreme Overbite or Underbite: Conditions leading to functional problems or pain.​

It’s essential to consult with a Medicaid-approved orthodontist who can assess the condition and provide the necessary documentation to support the claim of medical necessity.​

Medicaid Plan Codes for Orthodontic Treatment

Orthodontic treatment under Medicaid—such as braces—is only approved when it’s medically necessary. When submitting claims or requesting prior authorization, specific procedure codes (often CDT or CPT codes) are used to communicate the treatment type. These codes vary slightly by state but follow national standards.

Common Medicaid Orthodontic Codes

Important Notes for Providers and Patients

• Prior Authorization is required before starting treatment.
• Documentation like x-rays, photos, and bite evaluations must accompany claims.
• Codes must be submitted by a Medicaid-enrolled orthodontist.
• Failure to use the correct code will result in claim denial or delay.

Understanding Medicaid plan codes like D8080, D8660, and D8670 is essential for securing coverage for orthodontic treatment. While Medicaid typically covers braces for children under 21 (if medically necessary), adults usually face stricter criteria. Always verify with your state Medicaid office or provider for the exact coding and coverage rules.

The Application Process: Applying for Medicaid Orthodontic Coverage

Getting orthodontic treatment like braces through Medicaid involves a multi-step process. Since Medicaid only covers braces when they are medically necessary, the process includes eligibility verification, documentation, and state-specific approval procedures.

Step-by-Step Medicaid Orthodontic Coverage Application

1. Check Medicaid Eligibility

Before anything else, confirm if the applicant qualifies for Medicaid. Eligibility is based on:

• Household income (varies by state, but typically under 138% of the federal poverty level)
• Age (braces are usually covered for children under 21)
• Residency (must be a resident of the state where you apply)
• Disability or medical conditions (in some adult cases)

Apply for Medicaid through your state’s health department website or through the federal portal HealthCare.gov.

2. Enroll with a Medicaid-Approved Dentist or Orthodontist

Once Medicaid is active, schedule an exam with a Medicaid-participating general dentist. They will:

• Examine the child or patient
• Identify if a referral to an orthodontist is appropriate
• Provide initial documentation

The dentist may refer you to a Medicaid-certified orthodontist for further evaluation.

3. Schedule an Orthodontic Evaluation

The orthodontist will perform a comprehensive exam to determine if braces are medically necessary. This step often includes:

• Digital or physical impressions
• X-rays and panoramic images
• Photos of the teeth, bite, and profile
• Scoring with a Medicaid-approved index (e.g., Salzmann Index)

4. Submit Prior Authorization Request to Medicaid

If the orthodontist finds that the case qualifies, they will submit a prior authorization request to Medicaid. This request must include:

Initial Dental Exam
        ↓
Referral to Orthodontist
        ↓
Diagnostic Records + Evaluation
        ↓
Submit Prior Authorization
        ↓
Wait for Medicaid Approval
        ↓
Begin Treatment (if approved)

5. Wait for Approval from Medicaid

After submission, Medicaid will review the documents and determine if the treatment qualifies for coverage.

• Approval timelines vary by state (typically 2–8 weeks)
• Some states require scoring above a threshold (e.g., >26 points on the Salzmann Index)
• If denied, you have the right to appeal or submit additional evidence

6. Begin Treatment After Approval

Once approved:

• The orthodontist can start the treatment
• Medicaid will cover the costs according to state-specific guidelines
• Some states may require small copayments or cover certain services only partially

7. Maintain Routine Visits and Compliance

During the treatment:

• Attend monthly check-ups
• Maintain good oral hygiene (Medicaid may drop coverage if treatment is misused)
• Keep all Medicaid information updated

Summary: Medicaid Orthodontic Application Checklist

Note: Medicaid does not cover braces for cosmetic reasons. The need must be medically justified, often due to severe bite issues, speech difficulties, or jaw deformities.

Sample Medicaid Coverage Flow (Visual)

Initial Dental Exam
        ↓
Referral to Orthodontist
        ↓
Diagnostic Records + Evaluation
        ↓
Submit Prior Authorization
        ↓
Wait for Medicaid Approval
        ↓
Begin Treatment (if approved)

What Procedures Are Not Approved by Medicaid?

Medicaid does not typically cover procedures if they are:

• For cosmetic alignment
• Intended to improve appearance only
• Related to teeth whitening, shaping, or minor adjustments
• For adults, unless a severe medical condition exists

Diagnostic Services That Support Medicaid Approval

These supportive services are usually covered as part of the pre-treatment process:

Important Tips for Parents and Patients

1. Always use a Medicaid-certified orthodontist.
2. Ask your orthodontist about your child’s Salzmann Index score.
3. Submit complete documentation, including images, scores, and notes.
4. Understand that approval is not automatic, even if treatment is needed.

Medicaid-approved orthodontic procedures focus solely on medically necessary treatments that improve a child’s dental function and health. While many children qualify for braces under Medicaid, all cases require clinical justification through proper diagnostics and documentation. Cosmetic treatments are not eligible for coverage.

For instance, some states may cover orthodontic treatments for children when deemed medically necessary, while others might have more restrictive policies. Adults seeking coverage for braces may find that only a few states offer such benefits, and often only in exceptional cases.​

Choosing an Orthodontist Who Accepts Medicaid

Selecting the right orthodontist who accepts Medicaid can feel overwhelming, especially when balancing your child’s health needs with state coverage rules. But with the right information and a few tools, you can easily find a Medicaid-friendly orthodontist in your area.

Why It’s Important to Choose a Medicaid-Approved Orthodontist

Not all orthodontists accept Medicaid, and not all treatments are covered—even if braces are needed. Choosing a Medicaid-approved orthodontist ensures:

• You don’t pay out-of-pocket for covered services
• The provider understands Medicaid’s prior authorization process
• All documents are submitted correctly and timely
• Your child receives care aligned with Medicaid requirements

Step-by-Step: How to Find a Medicaid Orthodontist

1. Start with Your State’s Medicaid Website

Each state has its own directory of Medicaid-participating providers. Visit your local Medicaid website and search for:

• “Orthodontists accepting Medicaid”
• “Dental provider directory”
• “Medicaid dental specialists”

Example: InsureKidsNow.gov provides a national tool to find Medicaid dental providers.

2. Call Your Medicaid Insurance Provider

If you have a Medicaid managed care plan (like DentaQuest, MCNA, or Liberty Dental), call the number on the back of your Medicaid card. Ask:

• “Can you give me a list of orthodontists who accept Medicaid in my area?”
• “Is prior approval needed for orthodontic treatment?”

3. Ask Your General Dentist for a Referral

Your child’s dentist is often your best resource. Since Medicaid often requires a referral, your dentist can:

• Identify if your child’s condition may qualify
• Refer you to a trusted Medicaid-approved orthodontist
• Help with diagnostic imaging and paperwork

4. Use Online Directories & Tools

Questions to Ask Before Choosing

1. Do you accept my state’s Medicaid plan?
2. Do you handle Medicaid prior authorization paperwork?
3. What is the wait time for appointments?
4. Are emergency visits covered under Medicaid?
5. Do you offer free consultations for Medicaid patients?

What to Look For in a Medicaid Orthodontist

Common Mistakes to Avoid

• Assuming all orthodontists accept Medicaid: Always verify!
• Starting treatment before approval: Medicaid may deny retroactive claims.
• Not checking referral requirements: Many states require a dental referral first.
• Not understanding out-of-pocket charges: Some procedures may not be fully covered.

Bonus: Medicaid-Orthodontist Selection Checklist

Choosing a Medicaid-approved orthodontist is not just about finding someone nearby. It’s about working with a provider who understands the Medicaid system, can guide you through approvals, and offers compassionate, expert care for your child. Take time to research, ask the right questions, and follow your state’s specific steps to ensure full coverage.

Let me know if you’d like a downloadable version of the checklist or provider search links by state.

Steps to Determine Medicaid Coverage for Braces

If you’re considering braces and are a Medicaid beneficiary, follow these steps:

1. Consult a Medicaid-Approved Orthodontist: They can evaluate your dental condition and determine if braces are medically necessary.​
2. Obtain Prior Authorization: Most states require prior authorization for orthodontic treatments. This involves submitting documentation and justifications for the proposed treatment.​
3. Contact Your State’s Medicaid Office: They can provide detailed information on coverage specifics, including any state-specific requirements or limitations.​
4. Review State Guidelines: Familiarize yourself with your state’s Medicaid dental coverage policies to understand the scope of benefits and any associated processes.​

Appealing Medicaid Decisions: Your Rights and Procedures

If your Medicaid application for orthodontic treatment is denied, you have the legal right to appeal the decision. Every Medicaid recipient—child or adult—can challenge unfair denials, especially when the treatment is medically necessary.

When Can You File an Appeal?

You can file an appeal when:

• Your request for braces was denied
• Authorization for treatment was refused
• A previously approved treatment was canceled
• Medicaid says treatment is not medically necessary

Your Legal Rights in the Appeal Process

Under federal law and Medicaid regulations, you are entitled to:

• A written notice of denial
• A fair hearing before a judge or hearing officer
• Access to all records and evidence
• Assistance from a legal advocate
• Translation and interpretation services, if needed

Appeal Timelines You Must Know

Step-by-Step: How to Appeal a Medicaid Orthodontic Denial

Step 1: Review the Denial Letter

Carefully read the Notice of Action. It will explain why coverage was denied and how to appeal.

Step 2: Collect Supporting Documents

Gather:

• Orthodontist’s written evaluation
• Medical records
• X-rays or models of jaw and teeth
• Letters from doctors, speech therapists, or surgeons

Step 3: Submit the Appeal Request

Use your state Medicaid agency’s form or write a letter including:

• Your name and Medicaid ID number
• Reason you disagree
• Copies of your documentation

Step 4: Prepare for Your Hearing

During the fair hearing:

• You (or your representative) can present your case
• Witnesses like orthodontists or doctors can speak
• You can question the Medicaid agency’s reasons

Step 5: Attend the Hearing

The hearing can be in person, by phone, or via video. Be sure to:

• Have all documents ready
• Bring a family member or legal rep, if needed
• Clearly explain how denial affects your health

Step 6: Wait for the Decision

You’ll receive a written decision by mail. If successful, Medicaid must authorize treatment immediately. If denied again, you may appeal further to a higher court.

Sample Appeal Letter Template

[Your Name]
[Your Medicaid ID Number]
[Date]

To: State Medicaid Appeals Office

Subject: Appeal of Orthodontic Treatment Denial

Dear Appeals Officer,

I am writing to formally appeal the denial of Medicaid coverage for my orthodontic treatment. The treatment is medically necessary due to [explain reason – e.g., difficulty chewing, jaw pain, speech issues]. My orthodontist, Dr. [Name], has submitted supporting documents and diagnostic images showing the severity of my condition.

Attached are my clinical evaluations, X-rays, and letters from medical professionals recommending treatment. I request a fair hearing to present my case.

Sincerely,  
[Your Signature]  
[Your Phone Number & Address]

Tips to Strengthen Your Appeal

1. Act quickly – Don’t wait until the deadline is near.
2. Be specific – Clearly state your medical needs, not just dental concerns.
3. Get expert letters – Orthodontists, ENTs, pediatricians, and speech therapists add weight.
4. Practice your hearing explanation – Be confident and focused.
5. Consider legal help – Free legal aid services can assist with Medicaid cases.

Visual Flowchart of the Medicaid Appeal Process

A[Denial Notice Received] --> B[Review Denial Reason]
B --> C[Collect Medical Documents]
C --> D[Submit Written Appeal (within 30–90 days)]
D --> E[Attend Fair Hearing]
E --> F[Wait for Decision]
F --> G{Decision Outcome}
G -->|Approved| H[Orthodontic Treatment Authorized]
G -->|Denied Again| I[Optional: Appeal to Higher Court]

Don’t give up if Medicaid denies your request for orthodontic care. You have a legal pathway to fight back, especially when health is on the line. With clear documentation, timely filing, and confidence in your case, many applicants succeed in winning appeals.

Alternative Options if Medicaid Doesn’t Cover Braces

If Medicaid doesn’t cover braces in your case, consider the following alternatives:​

• State Children’s Health Insurance Program (CHIP): For families that don’t qualify for Medicaid but have limited income, CHIP may offer dental coverage, including orthodontics.​
• Dental Schools: Some dental schools offer orthodontic treatments at reduced costs, providing supervised training opportunities for students.​
• Payment Plans: Many orthodontic clinics offer financing options or sliding scale fees based on income.​
• Non-Profit Organizations: Certain organizations provide assistance or grants for orthodontic treatments to eligible individuals.​

The question, “Will Medicaid cover braces?”, doesn’t have a one-size-fits-all answer. Coverage depends on factors like age, medical necessity, and state-specific policies. For children under 21, there’s a higher likelihood of coverage if the braces are deemed medically necessary. Adults may face more limitations and should explore alternative options if Medicaid doesn’t provide coverage. Always consult with a Medicaid-approved orthodontist and your state’s Medicaid office to understand your specific situation and available option

15 detailed FAQs on the topic Will Medicaid Cover Braces?