This is a question we get nearly every day. Not only from folks here in Colorado but from around the country.
The short answer: maybe ….
Let us explain. First, Medicaid coverage for orthodontics varies by state policy. In some states Medicaid does provide coverage for some cases to be treated, while in others it does not. Here in Colorado, for example, there is Medicaid coverage for orthodontics. In all states, however, coverage is only for people under the age of 21. If you are 21 or over, have Medicaid, and want braces, we are sad to say that your insurance will not help you with the costs. You can still get braces, you will just have to pay for them yourself.
We should note that our practice has a somewhat unique understanding of this topic. A few years ago, in working with our state here in Colorado to design the state criteria, we performed a nation-wide analysis of state-by-state coverage. Later, as Dr. Baskin, one of our doctors, had been asked to help determine policy for the AAO on medical necessity, we updated this analysis for the AAO. Between these efforts, we came to realize that we might have a stronger grasp on this topic than almost any other practice in the nation.
So let’s say you live in a state that DOES offer orthodontic care and you have a child who you think could benefit from care. You may ask, how does it work? Well, to start, we need to provide a bit of “orthodontics 101” education. Orthodontics often has two different phases of treatment. Phase 1 (also called interceptive treatment) is for early care and is done often between the ages of 7-10 while the child’s jaw is still developing and they still have multiple “baby” (also called primary) teeth. This phase typically addresses more structural issues of the jaw such as a narrow palate, impacted teeth or an underbite. It is done early because a child’s jaw is far more malleable (for example at the top of the mouth, the palate has not yet formed) and so treatment can be done far more easily and quickly than it could in later years, sometime avoiding what would have been surgical solutions later down the road. Phase 2, or comprehensive treatment, is done for people for 10-99. It’s orthodontic care once most or all of the adult teeth have erupted in the mouth. It is important to note here that because some children would significantly benefit from early Phase 1 care, our national organization (called the AAO for American Association of Orthodontics) strongly recommends that all children see their orthodontist at age 7. Not every kid at 7 needs care, in fact most do not, but much like a checkup to the pediatrician, it’s important that children be “checked-out” by an orthodontist when they are 7 or 8.
So, back to Medicaid coverage. Most, but not all states that provide orthodontic benefits cover both Phase 1 and Phase 2 treatment. While rules change all the time, to the best of our knowledge there are still some states that do not cover phase 1 care. For either phase of care, before they will pay for anything, all states require that the need for the child to get braces is “medically necessary”. How do they determine medical necessity? Well again this varies by state. Each has developed its own set of criteria. Some use one of a few commonly accepted scoring mechanisms. With these, you get a certain number of points for exhibiting various conditions, and only if your point total meets or exceeds the required amount will the case be considered medically necessary. In other states, like here in Colorado, there is a checklist of criteria. In theory, if you meet any of the criteria on the checklist, you qualify for coverage. We say “in theory” because there is still a bit of a subjective element here. We have submitted cases that we think show 1 or more the criteria and have still had these cases denied for coverage. Why? Well, put simply, while our doctors may say that the x-rays and photos of a patient clearly show a condition, the folks who review the cases for the state may disagree. And in the end, the state reviewers have the final say.
“How often do kids get approved then?” you may ask. As you might imagine, again this varies greatly by state and phase of treatment. Politics and state budgets also sadly come into play. Here in Colorado, for example, as recently as 3 years again, we would often see about half of all kids get approved. More for Phase 2 than Phase 1, but just over 50% when taken together. Now, in the past year, that number has dropped to about a third. As the criteria for Phase 1 is more limited, this splits, roughly, to about 25% of Phase 1 cases being approved and about 40% of Phase 2. If you live outside of Colorado, these numbers could be drastically different.
The last piece to explain here is HOW Medicaid pays. Yet again, it varies by state. Here in Colorado, they will pay in full for a Phase 1 case. So, if you had Medicaid coverage on the day your evaluation consultation occurred and continue to have it on the day the braces or appliances are put on, you are all good. Even if you lose care the next day, the treatment has been paid for. Years ago, this also was true for Phase 2. But starting in 2017, Colorado changed these rules and now pays the doctor in installments. This can create some financial issues. If you lose coverage during treatment (Phase 2 often lasts about 2 years), you will most likely be responsible for paying the provider for the remaining care. What they charge you is completely up to them as, now that Medicaid is out of the picture, the practice can charge whatever they want. We know many of our competitors, for example, will charge $130-$150 a month for as many months as you still need treatment. Our practice, knowing the hardship on these families, decided to set a policy of charging $100/month and only charge for the number of months that we did not get Medicaid coverage (so no more than 18 months maximum, depending at what point the patient lost coverage). If you regain Medicaid coverage at a later date while still in treatment, the practice can attempt to re-apply for benefits and adjust your financials accordingly (you may still owe money for the period where there was no coverage). And yes, if you get private insurance during this time, this can sometimes be billed as well (depending on the policy).
So what do you do now armed with this knowledge? Well first, if you have a child over the age of 7 who has not seen an orthodontist (and yes, even if they have seen a dentist, they should be seeing an orthodontist who has 2-3 more years of training specifically on jaw and tooth development and correction), schedule to see one. It is painless for your child, free to you, and will assure they are getting the proper medical care they need. Secondly, as it relates to Medicaid coverage and approval, work with your orthodontist. They are on your side and want to get you covered as much as you do. They can advise if you get denied what the best next step may be (e.g., wait a year and try again, start with mild treatments that do not require approval but are covered by your insurance, etc.).
Lastly, if you are here in the metro Denver area, we’d LOVE to see you! We openly take all Medicaid patients (and to our knowledge are the only 5280 Top Orthodontist (and have been for 10 years!) and winner of the #1 practice in the state by Colorado Parent magazine that does so), and, while still a family-owned and operated practice, have 9 locations throughout the city to see patients. Just give one of our offices a call and schedule for a consultation.
We hope this all helps!