Medicaid is a healthcare program jointly funded by federal and state governments that supports low-income individuals and families. It provides coverage for an array of medical services, including dental and orthodontic care.
Should you or someone you know need orthodontic treatment, there are guidelines and requirements to determine if a person is qualified. Here’s a guide on what you need to know when looking for a Medicaid orthodontist and applying for coverage:
Medicaid Coverage Criteria
Coverage for orthodontic treatment is limited to individuals 21 years old and below, as the program prioritizes early intervention and preventive care. To ensure proper care is accessible regardless of financial capacity, eligibility is restricted to those with limited income and resources.
In addition, coverage is reserved for those with cleft palate or severe malocclusion leading to physical challenges. This means you must have teeth and jaw misalignment that significantly affects your ability to speak, chew, and maintain oral hygiene. Coverage is not extended for cosmetic purposes, such as addressing teeth spacing and overcrowding.
Coverage Limits
Medicaid coverage has limits on the duration and scope of treatment. The length of coverage depends on the severity of the dental issue, but Medicaid generally covers treatment for a period necessary to address the problem. Consult with your orthodontist and Medicaid provider to know the specific time limits in your state.
Exceptions to Coverage Limits: Extended Coverage Due to Medical Necessity
You may be eligible for extended coverage if your condition falls under any of the following:
- You have a condition affecting your ability to perform daily activities, including talking and eating. Coverage may be extended to address your functional limitations.
- You have craniofacial abnormalities impacting speech and causing physical pain.
- You have traumatic injuries or congenital conditions that affect your dental health.
Coverage for Braces
This varies by state. Generally, braces are covered when deemed medically necessary, which is also determined by the state. An evaluation process takes place to determine a child’s eligibility for braces, which includes an orthodontic severity scoring system.
What Benefits Can You Expect?
If deemed eligible, you no longer have to worry about the financial burden of all costs related to your orthodontic treatment. Medicaid can cover the majority, if not all, of the expenses, including the necessary dental services. Receiving the proper orthodontic care you need also means enhanced and long-term oral health.
Medicaid Plan Codes for Orthodontic Treatment
Codes are assigned to specific Medicaid plans. Here’s an overview of the codes to help you better understand the orthodontic services available for eligible beneficiaries:
D8210: Removable Appliance Therapy
This code is for removable appliances, such as retainers or aligners, that are used to correct minor orthodontic issues. This therapy is for those needing mild teeth straightening or alignment solutions.
D8220: Fixed Appliance Therapy
This is for more complex orthodontic conditions, such as patients who need braces. The coverage includes the cost of installation and maintenance of metal braces.
D8060: Interceptive Orthodontic Treatment of the Transitional Dentition
This code is for early orthodontic intervention for kids. The aim of this treatment is to guide tooth development and jaw growth to prevent severe malocclusion in children.
D8080: Comprehensive Orthodontic Treatment of Adolescent Dentition
This treatment corrects misalignment in teenagers or adolescents whose permanent teeth have fully erupted. The coverage includes comprehensive orthodontic care and services.
Medicaid Codes for Retainer Replacement
There are free retainer replacement services available for those under 20 years old to help them maintain their teeth alignment and oral health. Here are the Medicaid codes for retainers:
D8703: Replacement of Lost or Broken Retainer—Maxillary
Members ages 0 to 20 years are covered without needing prior authorization.
D8704: Replacement of Lost or Broken Retainer—Mandibular
Members ages 0 to 20 years are covered without needing prior authorization.
How to Apply for Medicaid Orthodontic Coverage
Before submitting your application, an important step is to be assessed by a licensed orthodontist who will confirm that your dental condition requires orthodontic treatment. Next, check if your state’s Medicaid program covers orthodontic services. You must then consult a practitioner to check if you qualify. If so, work on completing and submitting all necessary paperwork. This will be reviewed by a claims processor.
In two weeks or less, you will be informed of the result of the review process. Medicaid will simultaneously send the results by mail to the insured party. If you do qualify, you can proceed to plan and schedule your treatment with an orthodontist who accepts Medicaid as a form of payment.
Explore Financial Options and Learn How to Maximize Your Coverage
Even with Medicaid coverage, orthodontic treatment is a big step and a substantial financial commitment. Discuss your plan and options with a Medicaid orthodontist today to help you address any concerns you might have and ensure you will receive the best care possible.
