Most people who wish to undergo orthodontic treatment would like some flexibility when it comes to paying for the cost of the treatment as it is an expensive affair. Many of our patients want to know if Medicaid would be able to cover their charges or if there is some way we can help them to pay in a manner that is less burdensome for them. We will try and explore all the options that you can utilize to get on with your treatment without having to stress too much about how you will meet the costs.
Treatment with metal braces could be covered by Medicaid, but unfortunately, it does not cover cosmetic options like clear braces or Invisalign. Generally, Medicaid does cover orthodontic services only for children below 21 years of age and only those members who qualify under State Medicaid guidelines. Those guidelines could vary from state to state, however, in any case, the issue must be medically necessary, otherwise, your particular case will not be approved by Medicaid and you would have to self-pay for you or your child, in order to cover the cost of any orthodontic treatment.
If your child is under 21 years of age, then you need to take him or her to a Medicaid participating orthodontic facility for an initial evaluation by an orthodontist. During this consultation, the orthodontist will determine if your child meets the requirements to qualify for the state benefits, that decision will be based on the condition of yours or your child’s teeth and bite. If the orthodontist is convinced that your child does meet the qualifying requirements, then the orthodontist will take some pictures, x-rays and prepare impressions of the child’s teeth and draws up a treatment plan which will be sent to the managed healthcare plan through Medicaid. These records are scrutinized closely by the doctor employed by the state or managed care, who will decide whether the treatment is medically needed as per your particular state guidelines.
In any case, the treatment must be medically necessary in order for the state to approve the case. A point system is used to determine whether your child would qualify for Medicaid. One needs to score over twenty six points to qualify for benefits or have a condition that automatically qualifies for treatment like excessive overjet, front teeth into cross bite, impacted front teeth. There are quite a few other conditions that would automatically qualify and your orthodontist would be the best person to decide and help you. Even if you automatically qualify to get coverage, this automatic qualification, does not guarantee that the case will be approved. Your orthodontist cannot start treatment without a written approval from the managed care provider.
Once the state or managed care appointed doctor finishes his assessment, the insurance company will send a letter to you and a copy to your orthodontist’s office informing you whether you have been approved or denied to go ahead with your orthodontic treatment. If you have been denied, there is an appeal process that you can take advantage of to overturn the decision. But, if this does not work and you still do not qualify, then most orthodontic facilities will provide you with some flexible payment plans that will enable you to pay for the treatment.
If you do not have insurance and are worried about the interest you would have to pay, then be rest assured that usually there is no interest for payment plans. Most orthodontists will work with you on low flexible monthly payments that could fit your individual budget. You would have to pay some down payment first and the rest of the amount could be paid in installments throughout the year.
If you considering clear aligner therapy or cosmetic clear braces and you have Medicaid, you still have to pay yourself, since Medicaid does not provide any coverage for any cosmetic treatment options. Good news, however, metal braces work just the same if not better. Yes, they could be seen, but if you can save a lot of money, why not to choose them? If you have any questions regarding of the above, please contact your local orthodontist or two to get the right answers.