Does Medicaid Pay for Braces in Colorado?

Getting braces treatment in Longmont can be a big investment, and for Colorado families on Medicaid, it’s important to understand your coverage. If you’ve wondered, does Medicaid pay for braces in Colorado, the answer depends on age, eligibility, and medical need.

Health First Colorado, the state’s Medicaid program, offers orthodontic benefits in specific cases, usually when treatment is considered medically necessary.

Here’s when braces are covered, how much Medicaid will pay, and what the approval process involves so you can understand exactly how Medicaid’s orthodontic coverage works in Colorado.

Understanding Medicaid and Dental Coverage in Colorado

What is Health First Colorado?

Health First Colorado is the state’s Medicaid program, offering medical and dental benefits to eligible residents. Dental coverage includes preventive, restorative, and in some cases, orthodontic care. Eligibility is based on factors like income, household size, and age.

Children’s vs. Adult Dental Benefits

Children up to age 20 receive comprehensive dental services, including potential orthodontic coverage. Adults have more limited benefits than children, with fewer covered procedures and no orthodontic coverage.

How Much Does Medicaid Pay for Braces?

Children’s Coverage

For eligible children in Colorado, Medicaid typically covers the full cost of braces for kids when treatment is approved as medically necessary. Coverage applies only in cases of a severe bite problem that impacts function or health. The process requires prior authorization from Health First Colorado before treatment can begin.

When approved, Medicaid covers all related expenses, including exams, appliances, and adjustments, so families have no additional out-of-pocket costs for the orthodontic care provided.

Adult Coverage

For adults, Health First Colorado does not cover braces as part of its standard dental benefits. Even with the removal of the annual dental spending limit, orthodontic treatment remains excluded for members aged 21 and over. Only in extremely rare cases, typically tied to major surgery or severe medical conditions affecting jaw function, might braces be considered, and these require extensive documentation and prior authorization.

When Are Braces Medically Necessary?

In Colorado, Medicaid approves braces only when a severe malocclusion significantly affects chewing, speech, or jaw function. The case must meet the state’s specific medically necessary guidelines, and an orthodontist must provide documentation and diagnostic evidence for review before treatment can begin.

When approved, Medicaid typically covers the most cost-effective option, meaning not all types of braces are included. Coverage is usually limited to traditional metal braces rather than ceramic or clear aligners.

Examples of Qualifying Conditions

Common qualifying cases include a pronounced crossbite, extreme overbite or underbite, impacted teeth causing functional issues, and birth-related conditions such as a cleft palate.
These situations typically require corrective orthodontic care to improve oral health and overall quality of life.

Steps to Get Braces Covered by Medicaid

Initial Dental Exam

Start by visiting a Medicaid-approved orthodontist or dentist for a comprehensive evaluation. They will assess bite alignment, oral health, and determine if the case meets medical necessity standards for coverage.

Pre-Authorization Process

If the case qualifies, the provider will submit documentation, diagnostic records, and photos to Health First Colorado. Medicaid reviews the request and issues an approval or denial before treatment can begin, ensuring coverage eligibility is confirmed in advance.

Alternatives if Medicaid Won’t Cover Braces

Discount Dental Plans & Payment Options

Many orthodontic offices, like Longmont Braces, offer payment plans or in-house financing to make braces more affordable. Discount dental plans can also reduce the overall cost, sometimes covering part of exams, appliances, and adjustments.

Nonprofit & Community Programs

Certain nonprofit organizations and community programs provide reduced-cost orthodontics for children in need. Eligibility is often based on income and dental health, making these programs a valuable resource for families without full Medicaid coverage.

FAQs

Does Medicaid cover orthodontics in Colorado?

Yes, for children with severe bite problems that meet Medicaid’s medical necessity criteria. Orthodontics are not covered for adults under standard Health First Colorado benefits.

What makes braces medically necessary?

A condition that affects chewing, speech, or jaw function, such as severe malocclusion.

Does state insurance cover braces for adults?

No, orthodontics are not covered for adults under Health First Colorado’s standard dental benefits.

Are there free or low-cost options if Medicaid won’t cover braces?

Yes, through nonprofit programs and payment plans.

Does Medicaid cover Invisalign in Colorado?

Typically no, as coverage is usually limited to traditional metal braces unless clear aligners are deemed medically necessary.

How long does Medicaid take to approve braces?

Several weeks, depending on case review time.