Medicaid covers braces for children and teens when the orthodontic problem is medically necessary, not cosmetic. For adults, coverage varies dramatically by state, and most states don’t offer orthodontic benefits at all. Getting approved requires a specific process: a clinical evaluation, a scoring system that measures the severity of your dental issues, and a prior authorization request submitted by your orthodontist to the state.
Children Have Stronger Coverage Than Adults
Federal law requires every state Medicaid program to cover orthodontic treatment for children under 21 through a benefit called Early and Periodic Screening, Diagnostic, and Treatment (EPSDT). Under EPSDT, states must pay for any treatment that is medically necessary to correct a child’s physical condition, including braces. The key distinction is that orthodontic work done purely for cosmetic reasons is not covered. If a child’s misalignment causes functional problems like difficulty chewing, speaking, or breathing, or puts their oral health at risk, that’s where Medicaid steps in.
The determination is made on a case-by-case basis, taking into account the specific needs of each child. This means there’s no single national checklist. Your state’s Medicaid program sets its own threshold for what counts as medically necessary, and two children with similar-looking teeth could get different decisions depending on the clinical details.
Adults over 21 face a much harder path. States have complete flexibility over what dental benefits they provide to adult Medicaid enrollees, and there are no federal minimum requirements. Most states that do offer adult dental coverage limit it to emergency services, extractions, or basic preventive care. Orthodontics for adults is rarely covered unless it’s tied to a severe medical condition like jaw reconstruction after trauma or treatment related to cleft palate.
How States Decide If Braces Are Medically Necessary
Most states use a scoring system called the Handicapping Labio-Lingual Deviation (HLD) index to measure how severe your orthodontic problem is. An orthodontist takes precise measurements of your teeth and jaw, and each measurement gets a point value. If your total score hits a certain threshold, you qualify. In New York, for example, you need a combined score of 26 or more to be approved.
The scoring looks at several specific factors:
- Overjet: how far your upper front teeth stick out past your lower teeth, measured in millimeters
- Overbite: how much your upper teeth overlap your lower teeth vertically
- Open bite: the gap between your upper and lower teeth when your mouth is closed, multiplied by four in the scoring
- Ectopic eruption: teeth that have come in more than 50% outside their normal position in the arch, with each qualifying tooth multiplied by three
- Anterior crowding: when the arch doesn’t have enough room for the front teeth by more than 3.5mm, scored as five points each for upper and lower jaw crowding
- Reverse overjet (underbite): when lower teeth extend past the upper teeth, with each millimeter multiplied by five in the score
The multipliers mean that certain problems carry much more weight. A small underbite adds up fast because each millimeter counts five times, while crowding contributes a flat five points per arch regardless of how severe it is.
Conditions That Automatically Qualify
Some conditions bypass the scoring system entirely. If your child has any of the following, they automatically qualify for orthodontic coverage without needing to hit a point threshold:
- Cleft palate or craniofacial anomaly
- Deep overbite with soft tissue damage (upper teeth biting into the gum tissue behind the lower teeth)
- Crossbite of front teeth when it’s already causing gum recession or attachment loss
- Severe traumatic deviations (misalignment caused by injury)
- Impacted permanent front teeth that are stuck and can’t be resolved by extraction alone
- Overjet greater than 9mm with lips that can’t close naturally, or reverse overjet greater than 3.5mm with documented chewing or speech difficulties
Even if a patient doesn’t meet an automatic qualifier and doesn’t reach the scoring threshold, there’s still a possibility of approval. States can authorize treatment based on a professional assessment if the orthodontist documents a clear medical necessity. This is an exception, not the standard path, but it exists.
Steps to Get Approved
The process starts with a visit to a dentist or orthodontist who accepts Medicaid. Not every orthodontist does, so you’ll need to confirm this before scheduling. The federal government maintains a dentist locator tool at InsureKidsNow.gov where you can search for Medicaid-enrolled providers in your area. You can also call your state Medicaid office or the number on the back of your Medicaid card to request a provider list.
At the initial appointment, the orthodontist examines the teeth and jaw, takes X-rays and impressions, and determines whether the case meets your state’s medical necessity criteria. If they believe it qualifies, they submit a prior authorization request to your state’s Medicaid program (or to your managed care organization if you’re enrolled in a Medicaid managed care plan). This request includes clinical documentation: measurements, photos, X-rays, the HLD score, and a written explanation of why treatment is necessary.
The state or managed care plan reviews the submission and issues a decision. Straightforward cases where the documentation clearly demonstrates necessity tend to get approved without much back and forth. If the reviewer leans toward denial, some plans offer a peer-to-peer review where your orthodontist can discuss the case directly with a clinical reviewer on the insurance side. This is essentially a chance for your provider to argue the case before a formal denial is issued.
If your request is denied, you’ll receive a written notice explaining why. You have the right to appeal. The appeal process varies by state, but it typically involves submitting additional documentation or requesting a fair hearing. Ask your orthodontist’s office to help with the appeal, since they’ll need to provide the clinical evidence.
Why Finding a Provider Can Be Difficult
One of the biggest practical barriers to getting braces through Medicaid isn’t the approval process itself. It’s finding an orthodontist willing to take your case. Medicaid reimbursement rates for orthodontic treatment are significantly lower than what private insurance pays, and many orthodontists limit the number of Medicaid patients they accept or don’t participate in the program at all.
Start your search early. Dental schools and university orthodontic programs are often good options because they accept Medicaid more consistently than private practices, and the work is done by residents under faculty supervision. Community health centers that receive federal funding may also offer orthodontic services or referrals. If you’re in a rural area, be prepared that the nearest Medicaid-accepting orthodontist could be a significant drive away.
Once you find a provider, expect a wait. Many Medicaid-enrolled orthodontists have long waitlists, sometimes six months or more before treatment begins. Getting your name on the list as soon as you have a referral helps.
What to Expect During Treatment
If approved, Medicaid covers the cost of the braces themselves, adjustments, and follow-up visits through the course of treatment, which typically runs 18 to 24 months depending on the complexity of the case. Some states cover both traditional metal braces and clear aligners, while others only cover metal brackets. Retainers after treatment are generally covered as well, since they’re considered part of the orthodontic care plan.
You likely won’t have any out-of-pocket cost for a child’s treatment under EPSDT. Some states charge small copays for dental visits, but many waive copays entirely for children. Your orthodontist’s office should be able to confirm whether any cost-sharing applies in your state before treatment starts.
Keep every appointment. Missing adjustment visits can extend treatment time, and in some cases, Medicaid may stop covering treatment if there’s a pattern of missed appointments or noncompliance with care instructions. If you need to reschedule, do it promptly.