Medicaid, a public assistance program funded jointly by the federal and state governments, provides healthcare coverage to millions of low-income Americans. Dental care, particularly for adults, is often one of the most limited benefits within the program. While braces are a common procedure, they are frequently classified as an elective treatment, which is generally not covered. Coverage ultimately depends on a narrow definition of medical necessity and the age of the patient.
The Policy Distinction Between Cosmetic and Necessary Care
Medicaid covers services deemed medically necessary for the diagnosis and treatment of disease, injury, or physical conditions. This framework is why orthodontic procedures are typically excluded from coverage. Routine braces for minor tooth alignment or aesthetic concerns are generally considered cosmetic or elective procedures, which fall outside the program’s mandate.
The federal minimum requirements for adult dental benefits are extremely limited. In many states, adult coverage is restricted to emergency services for pain relief or infection treatment. Comprehensive services like orthodontics for adults are almost universally excluded because states are not required to cover non-essential dental care. Medicaid’s focus is on maintaining basic health and function, rather than improving appearance.
Mandatory Coverage for Children Under EPSDT
A significant exception to the exclusion of braces exists for Medicaid-eligible individuals under the age of 21 through the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit. EPSDT is a mandatory federal requirement that ensures comprehensive health services for children and adolescents enrolled in Medicaid. The mandate requires states to provide any necessary health care service to “correct or ameliorate” defects and physical or mental illnesses.
If an orthodontic condition is discovered during a screening and is determined to be medically necessary to treat a functional problem, Medicaid must cover the cost of braces. The EPSDT provision ensures that children receive treatment for malocclusion, or poor tooth alignment, when it impacts their ability to eat, speak, or maintain oral hygiene. The services must be provided regardless of whether they are included in the state’s standard Medicaid plan, as long as they are deemed medically necessary.
Criteria Used to Determine Medical Necessity
Since EPSDT coverage hinges on medical necessity, states utilize specific criteria to evaluate orthodontic cases. The process begins with a Prior Authorization (PA) request submitted by a Medicaid-approved orthodontist after a comprehensive evaluation. This documentation must include X-rays, photographs, and models to demonstrate the severity of the malocclusion.
Many states employ standardized scoring systems, such as the Handicapping Labio-Lingual Deviation (HLD) Index, to quantify the severity of the dental issue. These indices assign points based on measurements of misalignment, crowding, or bite problems, requiring a minimum score for treatment approval. Conditions that usually qualify include severe overbites or underbites that interfere with chewing function, congenital abnormalities like cleft palate, or severe crowding that makes oral hygiene impossible. Orthodontic care is approved only if the condition significantly impairs function or overall health.
State Variations and Rare Adult Exceptions
While federal law mandates EPSDT coverage for children, adult dental benefits are left to the discretion of each state, leading to variability in coverage. Nearly all states offer adult dental coverage, but this often remains limited to emergency extractions or basic restorative services. A handful of states have expanded their coverage to include comprehensive services like crowns and root canals, yet this rarely extends to orthodontic treatment.
Orthodontic coverage for adults is exceptionally rare and restricted to highly specific, medically complex situations. Braces may be covered if required as an integral part of a larger treatment plan, such as preparation for jaw surgery (orthognathic surgery) to correct a severe skeletal deformity. Coverage may also be considered in cases resulting from severe trauma or to correct a condition related to a serious medical illness. Even in these rare scenarios, a rigorous prior authorization process is required to prove that the procedure is necessary to restore function, not merely to improve appearance.