Medicaid covers braces at no cost to the patient when orthodontic treatment is deemed medically necessary, but only for children and young adults up to age 20 in most states. The catch is that “medically necessary” has a high bar, and what qualifies varies significantly from state to state. If your child does qualify, Medicaid typically pays the orthodontist directly, and families owe nothing out of pocket.
What Medicaid actually reimburses orthodontists, though, is far less than what private-pay patients are charged. That gap creates real challenges in finding a provider who accepts Medicaid for braces.
What Medicaid Pays Orthodontists
Private braces typically cost between $3,000 and $7,000 depending on the type and complexity. Medicaid doesn’t pay anywhere near that. On average, Medicaid reimburses dentists at about 49% of what commercial dental insurance pays for pediatric dental services. For orthodontic treatment specifically, reimbursement rates vary by state but commonly fall in the $2,000 to $3,500 range for a full course of treatment, sometimes less.
This low reimbursement is a major reason many orthodontists don’t accept Medicaid patients. The treatment itself takes 18 to 24 months on average, requiring regular adjustment visits, and the payment often doesn’t cover the provider’s costs. If you’re looking for a Medicaid-accepting orthodontist, expect a limited pool of providers and potentially longer wait times for appointments.
Who Qualifies for Coverage
Federal law requires every state’s Medicaid program to cover medically necessary orthodontic services for children through the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit. This applies to Medicaid-enrolled individuals from birth through age 20. The key phrase is “medically necessary.” Braces for purely cosmetic reasons, like mildly crooked teeth, are not covered.
To qualify, a child’s bite or jaw alignment problem generally needs to cause functional issues: difficulty chewing or speaking, chronic pain, or physical deformity. The American Association of Orthodontists recognizes several conditions that automatically establish medical necessity:
- Severe overbite: upper front teeth protruding 9 millimeters or more beyond the lower teeth
- Craniofacial anomalies: jaws or teeth significantly affected by a congenital disorder, cleft palate, trauma, or disease
- Multiple missing teeth: at least one congenitally missing tooth per quadrant of the mouth (not counting wisdom teeth)
- Severe crowding or spacing: 10 millimeters or more of crowding or gaps in either the upper or lower arch
How States Decide: The Scoring System
Most states use a standardized scoring tool called the HLD index (Handicapping Labiolingual Deviation) to measure the severity of a child’s orthodontic problem. Points are assigned for factors like how far teeth are out of alignment, the degree of overbite or underbite, and whether teeth are impacted. The total score determines whether treatment is approved.
Here’s where it gets frustrating: each state sets its own passing score. California requires a score of 26 on the HLD index before Medicaid will cover braces. Maryland only requires a score of 15. That means a child who qualifies for braces in Maryland could be denied for the exact same condition in California. The National Health Law Program has noted that these cutoffs are essentially arbitrary and lead to inconsistent access depending on where a family lives.
Some states also have automatic qualifying conditions that bypass the scoring system entirely, such as an overbite greater than 9 millimeters with the inability to close the lips, a reverse bite greater than 3.5 millimeters causing chewing and speech problems, or severe trauma-related deviations.
The Approval Process
Getting Medicaid to cover braces requires prior authorization in nearly every state. This isn’t a quick process. Your child’s dentist or orthodontist will need to submit a formal request that typically includes panoramic X-rays, cephalometric X-rays (a side-view image of the skull and jaw), photographs of dental models, and intraoral photos. The provider also documents the clinical assessment explaining why treatment is necessary.
The state’s Medicaid program or its contracted dental administrator then reviews the submission, applies the HLD scoring system or its own criteria, and either approves or denies the request. This review process can take several weeks. If denied, families can appeal the decision, and in many states, an independent review is available.
Adult Coverage Is Extremely Limited
For adults over 21, Medicaid orthodontic coverage is rare. Federal law only mandates dental coverage for children through the EPSDT benefit. States can choose to offer adult dental benefits, but most that do limit coverage to emergency extractions, dentures, or basic preventive care. Orthodontics for adults is almost never included.
A few states make narrow exceptions. West Virginia, for example, covers orthodontic treatment combined with jaw surgery for adults if the surgery was documented in the original orthodontic plan of care. Delaware provides no dental coverage at all for adults. New York offers extensive adult dental benefits including preventive care, periodontal treatment, and oral surgery, but specifically excludes orthodontics. These examples illustrate how dramatically coverage varies by state.
Options When Medicaid Doesn’t Cover Braces
If your child doesn’t meet the medical necessity threshold, or if you’re an adult without orthodontic coverage, there are a few alternatives worth exploring. Dental schools with orthodontic residency programs often provide braces at 50% to 70% of private practice fees, with treatment supervised by licensed faculty. Many orthodontists also offer in-house payment plans that spread the cost over the length of treatment without interest.
Nonprofit organizations provide another avenue. The AAPD Foundation funds community-based dental care programs through grants to clinics, hospitals, dental schools, and local health departments. These grants support organizations that offer free or reduced-cost dental care to children from families who can’t afford it. While the foundation doesn’t pay families directly, the clinics they fund may provide orthodontic services at little or no cost. Local community health centers with dental programs are often the most accessible starting point for finding sliding-scale orthodontic care.