09 Apr 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 “Prices depend on where you [the patients] live – orthodontists in more rural areas are often less expensive than ones in larger cities – and may be at the orthodontist’s discretion” (“How Much Do Braces Cost?”). People may be able to utilize dental insurance or supplemental orthodontic insurance to help pay for their braces (Haney 2018c; “How Much Do Braces Cost?”). However, they may also be able to utilize their health insurance and Medicaid.
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, such as a “nicer smile to improve appearance…” (Haney 2018b). However, adults can get health coverage for braces if they are medically necessary to “[prevent], [diagnose], or [treat] an injury, disease, or symptoms” (Haney 2018b). Some of these injuries or diseases may include “Non-biting accidents that affect the positioning of your [adults’] teeth in the mouth,” “Temporomandibular Joint Disorders (TMJ or TMD) requiring bite adjustments,” and “Sleep apnea when crooked teeth restrict or block airflow” (Haney 2018b). Though, some health insurance policies may not cover braces treating TMJ because “the treatment is controversial. Braces for TMJ do not work very well and often cause the problem to worsen. There is no clear benefit to the patient” (Haney 2018c). People need help from their orthodontist or medical doctor “to prove that your [patients’] desired orthodontic procedure is medically necessary” (Hirby). Adults could also pay more for their health insurance policy by “add[ing] comprehensive dental coverage” in order to receive benefits for orthodontic procedures (Hirby). Sometimes, their employer’s medical insurance may have benefits for orthodontic procedures (“How Does Orthodontic Insurance Work?”).
Adults can also utilize Medicaid coverage for orthodontic procedures. However, the dentist must prove that the braces are “medically necessary” for adults (“Does Medicaid Pay For Braces?”; Haney 2018a). Consequently, people should collaborate with their dental provider “to develop a narrative documenting why the treatment relates to an accident or disease” (Haney 2018a). Adults could receive Medicaid coverage if they need braces treating conditions, such as “an accidental injury, TMJ, or sleep apnea” (Haney 2018a). 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” (Haney 2018b). Unfortunately, few orthodontists accept Medicaid due to “the strict qualifying criteria and low reimbursement rates. In addition, the long treatment periods cause billing and collections issues” (Haney 2018b). Also, the lifetime maximum may affect the amount of Medicaid coverage for braces (“How Much Do Braces Cost?”).
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. Consequently, adults can pay for their orthodontic procedures more easily.