Does Medicaid cover braces?
Last verified:
For children, when medically necessary under EPSDT; for adults, almost never. Federal rule: epsdt for under-21; optional dental for adults.
What federal law says
Braces are not named in federal regulation. They live inside dental services, which are optional for adults and mandatory for children through EPSDT. That makes the child's case strong and the adult's case weak.
States use a handicapping malocclusion index or a similar scoring tool to decide whether a child's braces are medically necessary, with prior authorization from the orthodontist. Denials are appealable, and the appeal often turns on whether the dentist documented function, such as chewing or speech, rather than appearance.
For adults, braces would have to fit inside whatever adult dental benefit the state offers, and even states with extensive adult dental generally exclude orthodontics as cosmetic.
Children under 21
Orthodontics falls under EPSDT dental for anyone under 21, but only when medically necessary, and each state defines that with a scoring index of how severe the bite problem is. Crowding that is cosmetic does not qualify; a bite that affects eating or speech usually does.
What to ask your state plan
- Ask the orthodontist to submit the prior authorization with the state's scoring form filled in; a bare request is the usual reason for denial.
- If a child is denied, request the scoring sheet and the appeal deadline in writing.
- Find your state's agency, program name and phone on Medicaid by state.
Related questions
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Common questions
Does Medicaid cover braces?
For children, when medically necessary under EPSDT; for adults, almost never.
Does Medicaid cover braces for children?
Orthodontics falls under EPSDT dental for anyone under 21, but only when medically necessary, and each state defines that with a scoring index of how severe the bite problem is. Crowding that is cosmetic does not qualify; a bite that affects eating or speech usually does.
How do I find out whether my state's Medicaid covers braces?
Three places. Your plan's member handbook or benefit summary, which lists the covered services and limits; the state Medicaid agency's provider manual for the service, which is public and states the medical-necessity criteria; and the member services line on your card, which can run a coverage check for a specific procedure code. Our state pages list each agency's phone and portal.
Sources
- medicaid.gov: EPSDT (children under 21)
- medicaid.gov: dental care
- 42 CFR 440.230 (amount, duration and scope of services)
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