Does Dental Insurance Cover Braces?
Yes, dental insurance can cover braces, but only in some situations. Braces are covered by insurance when:
- You have dental coverage that covers braces: Your insurance plan states that it covers orthodontic treatment.
- You have an ACA plan and are under 19: Braces for children may be covered by an ACA plan if medically necessary.
- You have Medicaid coverage: For children, state-based Medicaid may cover braces when medically necessary; only three states cover braces for adults.
While 80% of the U.S. population has dental insurance, not all cover orthodontic treatment. In most situations, insurance won’t cover all costs of orthodontic treatment. For example, there will be some leftover costs after the insurance coverage. For example, insurance may cover 50% of your expenses up to a limit of $1000. If braces cost $6,000, you’ll still need to pay $5,000.
Table of Contents
What Are Braces?
Teeth braces, or orthodontic braces, are dental devices used to align teeth and correct various orthodontic issues like crooked teeth, overcrowding, and misaligned jaws. Orthodontic treatment with braces improves the smile’s appearance and helps maintain better oral health by facilitating easier cleaning and reducing the risk of dental problems.
What’s more, braces are becoming increasingly prevalent in the U.S. About 65% of adults do not have well-aligned front teeth, and 4 million Americans have or need braces.
How Does Dental Insurance For Braces Work?
Dental insurance for braces typically covers most of the treatment required but only for some populations (such as children) or up to a certain percentage and limit.
Orthodontic Services Covered By Dental Insurance
Depending on your plan, standard orthodontic services covered by dental insurance may include the following:
- Exams and visits, including pre-treatment, initial, and ongoing visits
- Orthodontic records, including X-rays, diagnostic casts, photographs, and films
- Braces, including fixed and removable metal, ceramic or plastic braces (aligners)
- Orthodontic treatments or preparatory treatments, such as extractions
However, some plans may not cover all procedures, treatments, exams, and devices or only cover up to a specific percentage or limit. In addition, dental insurance may not cover the following:
- Replacement or repair costs for devices (such as a retainer)
- Self-administered orthodontics
- Jaw (orthognathic) surgery
When Does Dental Insurance Cover Braces?
Dental insurance covers braces in specific situations, such as when you have group or family coverage for children. Insurance may also cover medically necessary braces according to state or standard definitions.
Dental Insurance With Coverage for Orthodontics
Most dental insurance covers preventive care, root canals, restorative care (fillings and crowns), and oral surgery. However, many Americans get dental insurance through their employer or a group plan, which is more likely to cover a certain percentage of orthodontic treatment. Many larger dental insurance companies also offer an extra fee for a minimal orthodontics coverage option.
Orthodontic insurance doesn’t exist as a stand-alone plan. Instead, it’s typically an add-on plan to your existing dental coverage, for which you pay an additional premium. If added, orthodontic benefits usually extend to others on your plan. However, orthodontics coverage may only pay for your kids’ braces—reading through for any exclusions is essential.
ACA-Marketplace Family Plans
Almost 9% of Americans with private dental coverage access it through the health insurance marketplace. The 2010 Affordable Care Act required health plans to include a pediatric dental benefit covering orthodontic care if “medically necessary.” States set medically necessary criteria but usually draw on the definitions supplied by the American Association of Orthodontics (AAO).
Braces and other orthodontic treatments may be available for those 19 and younger with serious issues, such as an identifiable syndrome (such as cleft lip) or severe craniofacial deformities that cause further problems, including pain, suffering, and malfunction. Keep in mind that most plans do not cover braces for crooked teeth and other milder situations.
Another 94 million Americans receive dental coverage through government programs such as Medicaid, Medicare, Medicare Advantage, Children’s Health Insurance Program (CHIP), or TriCare for military service members.
Adult dental Medicaid benefits vary by state, and orthodontia is only covered in three states. Medicaid offers far more coverage for children, but children may need to meet strict qualifications. For example, in Ohio, braces are restricted to those under 21 and only in extreme cases with state approval.
When Does Dental Insurance Not Cover Braces?
You’ll likely have difficulty finding an independent dental plan that covers adult orthodontic services or as much as you hope. Even with many insurance types outlined above, dental insurance may not cover braces when:
- You’re an adult
- When treatment doesn’t meet requirements for being medically or dentally necessary
- If you’ve already started treatment already under a different plan
- If you started treatment before the insurance’s required waiting period expired
Does Medicare Cover Braces?
About two-thirds of older adults have dental coverage, which is lower than the average population. Original Medicare doesn’t cover most dental care, even basic care such as cleanings and fillings. Medicare Advantage may offer dental coverage and other services Original Medicare doesn’t cover.
However, these plans strive to provide basic dental care, such as preventive dental exams, cleanings, and X-rays. They also may cover restorative work, such as fillings, extractions, and root canals. Typically, this basic care doesn’t include orthodontic work and braces.
Paying for Braces With Insurance
If an insurer covers braces, only a portion of the costs are typically paid for. This may be a percentage of the treatment fees and a specific dollar amount for use over your lifetime. Insurance may also limit your treatments or appliances, such as one retainer every six years.
At most, insurance usually pays only around $2000-$4000 of the total costs, with $1000 to $1500 more typically seen. As noted earlier, this is lower than the total cost of braces from start to finish, which may be even higher if there are multiple treatment phases. Here’s how it works.
If your dental insurance covers braces, make sure to pay attention to the following costs:
- Coinsurance: Insurance typically only pays a portion of any charge, usually 50%. You pay the remaining 50% of the costs.
- Benefit maximum: Insurance pays only up to a specific limit. Generally, $1000 or $1500 are typical at the lower end, with up to $2,000 per adult and $4,000 per child at the higher end. This is a lifetime maximum; you don’t get a new yearly limit next year, which can be challenging if your child has multiple treatment phases.
- Deductibles: Depending on the plan, orthodontic treatment may or may not require paying a lifetime-applicable deductible; deductibles may be lower if you pay a higher premium.
Out-of-pocket costs for insurance-covered braces mainly depend on your plan and the total amount covered.
Covered By Insurance?
Repair or replacement of damaged orthodontic appliances (retainers)
Most orthodontic services will be covered up to your limit. Still, exceptions exist, particularly if you need expensive surgeries or hope to replace a third (or more) lost retainer. Self-administered orthodontics may be partially covered by insurance or not at all.
Depending on your plan, other restrictions may apply, including waiting periods before you can start treatment, coverage for only specific age groups (under 19), and not covering treatment listed as “dentally necessary” or “medically necessary.” In those cases, you’ll pay all costs out of pocket.
Your plan determines how networks impact braces access, pricing, and coverage. Some insurance plans give you the choice of going to any licensed orthodontist, while others may require you to visit a provider within the insurance plan’s network, referred to as “in-network.” These in-network orthodontists contract with insurance companies to provide consistent pricing for plan members.
Even if you’re not required to stay within the insurance network, you may find that in-network orthodontists supply you with lower costs or easier claims and payment processing. For example, the orthodontist might submit the claim for you versus you paying the claim, then submitting it to the insurer for reimbursement.
Using FSAs and HSAs To Pay For Braces
You can use healthcare flexible spending accounts (FSAs) and health savings accounts (HSAs) to cover costs associated with braces and orthodontia. With an HSA, you put money in tax-free and withdraw it tax-free. Money rolls over in the account to the following year, even if you don’t use it all. FSAs are less flexible, and only some funds may roll over.
Both often come with debit cards you can use to make payments for qualified expenses, such as orthodontic treatments and visits, or you can submit a one-time lump sum or monthly expenses for reimbursement. Keep detailed receipts to submit as proof of expenses paid.
Is Financial Aid Available For Braces?
The American Association of Orthodontists Foundation (AAOF) ‘s Donated Orthodontic Services (DOS) program helps children 18 and younger with orthodontic interventions, including braces. Families qualify based on household income and several other factors. You can apply through the AAO website.
You can also investigate orthodontic services from your local college of dentistry. Orthodontic residents (orthodontists in training) will practice skills, and you get a discount, sometimes as much as 50% off the standard pricing.
You could also consider dental discount plans. These plans save you a percentage on preventive and significant dental costs, including orthodontics—as long as you stay in-network.
Further, most orthodontists accept credit cards if you don’t qualify for the above. However, credit card interest is usually very high. Some orthodontists offer financing or payment plans for all or a portion of the costs, at lower interest rates, with regular monthly payments.
How To Get Braces Covered By Insurance
Here are steps to determine whether you can get insurance to cover braces costs and how to shop for a plan that does.
Check Your Current Insurance
There are three ways to find out if your current insurance covers braces:
- Speak with your human resources department: This person may have an extensive understanding of your dental insurance plan.
- Call your insurance company. Call your company and ask if braces are covered and if there are any rules around coverage, such as metal, ceramic, and ins.
- Review your plan description for specific coverage requirements, dollar limitations, and exclusions. However, you may still need to speak to someone to clear up any confusion.
Research Different Insurance Plans
You can search for plans through the Health Marketplace or your state insurance department.
If you’re interested in switching plans and have already started orthodontic services, ask the potential plans if coverage is available for “orthodontic work in progress” or if any additional requirements apply to get coverage.
Compare plans for coverages and provider networks:
- Inclusions and exclusions: Is two-phase orthodontic treatment covered? Which procedures? Which types of braces?
- Waiting period: How long must you wait before starting treatment?
- Out-of-pocket costs: Deductible requirements, maximum dollar amount and/or percentage of coverage allowed, and any lifetime limits
- Networks: If you can choose any orthodontist or must choose from the insurance company’s list of providers. If so, ask if you can see how many orthodontists are on the list.
Choose Your Plan
After choosing a plan that works for your needs and budget, you’ll apply for the plan with the insurance company. Most plans charge monthly premiums for an annual plan, with the plan premium deducted automatically from your checking account.
Upon receiving proof of your dental insurance plan, you can shop for orthodontists. If you need an in-network orthodontist, you can either call the orthodontist’s office to ask if they’re in-network, or the insurance company may have a searchable online directory or phone number to call. However, always make sure with the orthodontist that they accept your plan before committing to a treatment plan.
Alternatives To Traditional Braces
Recent technological advances have led to new alternatives to the full-metal mouth of the past. Consider these two options if you want something more gentle or less noticeable.
As with metal braces, a signature treatment feature involves brackets applied to each tooth. However, those brackets are made of ceramic versus metal. Thin metal alloy wires thread through each bracket. The overall appearance can be more natural, and the physical pressure associated with tooth movement is more comfortable and gentle. Self-ligating ceramic braces are another option and are even less visibly noticeable.
Ceramic braces may cost slightly more than traditional braces. If insurance doesn’t explicitly cover ceramic braces, you may still qualify for coverage for any treatment you choose, including plastic aligners. This allowance can reduce your total bill.
Plastic braces may also be called aligners and may be best for people needing mild to moderate treatment for gapped, crooked, or crowded teeth. Aligners are clear plastic trays molded to fit your mouth, slowly moving your teeth into the correct position. Generally, you wear an aligner for a week or so, removing trays while eating or brushing your teeth.
Insurance may or may not cover plastic braces, which typically cost more than traditional braces. But because most plans give you a fixed lifetime amount toward orthodontic treatment, you may be able to use it for any braces treatment you choose, including plastic aligners. This allowance can reduce your total bill.
Insurance could potentially help pay for orthodontic treatments such as braces. However, many plans have limitations and exclusions and won’t pay the total cost for braces. If you’re buying dental insurance, understand braces coverage before enrolling. Compare paying the premium for 1-4 years during the treatment period versus any lifetime savings you’ll benefit from. Usually, insurance only pays up to a percentage, such as 50%, along with a lifetime limit, such as $1,500. However, you’re responsible for paying the remaining costs out of pocket.
You may need to turn to an orthodontist’s payment plan, personal loan, or savings to make up the difference. You can also ask about any cost savings for paying the cost upfront in one lump sum or other discounts.