Health and Medicaid Coverage for Orthodontic Procedures

Adults can undergo orthodontic treatments for cosmetic and medical reasons. Unfortunately, braces can be expensive for some people, but they may be able to utilize dental insurance or supplemental orthodontic insurance to help pay for their braces. However, they may also be able to utilize their health insurance and Medicaid.

Health Insurance and Orthodontic Procedures

Depending on their condition, adults can use their health insurance benefits for orthodontic procedures. They usually cannot receive health coverage for orthodontic treatments if they want them for cosmetic reasons. However, adults can get health coverage for braces if they are medically necessary to treat an injury or disease. Some of these injuries or diseases may include accidents that affect your teeth, temporomandibular joint disorders, and sleep apnea when crooked teeth restrict or block airflow. However, some health insurance policies may not cover braces for treating TMJ because it is a controversial treatment due to its inconsistent effectiveness.

People need help from their orthodontist or medical doctor to prove their orthodontic procedure is medically necessary. Adults may also have the option to pay more for their health insurance policy by adding comprehensive dental coverage to receive benefits for orthodontic procedures. Sometimes, their employer’s medical insurance may have benefits for orthodontic procedures.

Medicaid and Orthodontic Procedures 

Adults can also utilize Medicaid coverage for orthodontic procedures. However, the dentist must prove that the braces are medically necessary for adults. Consequently, people should collaborate with their dental provider to ensure the treatment relates to an accident or disease. Adults could receive Medicaid coverage if they need braces treating conditions such as an injury, TMJ, or sleep apnea. In Oregon and Washington, D.C., if adults want orthodontic procedures for cosmetic reasons, they could receive Medicaid coverage but, “the orthodontist will have to demonstrate a ‘handicapping malocclusion’ according to the local rules.”

Unfortunately, few orthodontists accept Medicaid due to the strict qualifying criteria and low reimbursement rates. Also, the lifetime maximum may affect the amount of Medicaid coverage for braces.

With the help of their dental provider, adults can prove that their medical condition justifies their need for braces in order to receive coverage from health insurance and Medicaid. This allows them to pay for their orthodontic procedures more easily.  

If you are struggling with orthodontic billing consider partnering with eAssist. Our Success Consultants are familiar with orthodontic treatments and will ensure they are billed correctly. To learn more, schedule a consultation here.

Sandy Odle

Co-Founder and CXO, eAssist

Sandy Odle is the Co-Founder and CXO of eAssist Dental Solutions, where she has played a key role in shaping the company’s business and marketing strategies, leading to record growth and national recognition on the Inc. 500 and Utah Top 100 lists. A passionate social entrepreneur, Sandy believes that business is about building meaningful connections and creating personalized solutions that truly meet customer needs. Her relentless commitment to delivering exceptional client experiences is at the heart of eAssist’s mission. Drawing on the discipline and attention to detail honed during her early career as a ballet dancer, Sandy brings a unique blend of creativity, precision, and work ethic to everything she does.