In New York, child and teens who are covered by Medicaid can receive orthodontic treatment, including braces, if they meet certain criteria.

Here's how the process generally works:

 

Eligibility and Criteria for Medicaid Braces

1. Medicaid Coverage: Ensure that the patient is enrolled in Medicaid. This can be confirmed through the Medicaid managed care plan or directly with New York Medicaid.

2. Medical Necessity: Orthodontic treatment, including braces, is typically covered by Medicaid only if it is deemed medically necessary. This often means there must be significant dental issues that affect the patient's ability to eat, speak, or maintain oral hygiene, such as severe malocclusion, misalignment, or other dental deformities.

 

Steps to Obtain Medicaid Braces

1. Initial Dental Visit: Schedule an appointment with a Medicaid-approved dentist. The dentist can provide an initial examination and determine if there are significant orthodontic issues.

2. Referral to an Orthodontist: If the dentist believes orthodontic treatment is necessary, they will refer the patient to a Medicaid-approved orthodontist for further evaluation.

3. Orthodontic Evaluation: The orthodontist will perform a comprehensive evaluation, including taking X-rays, photographs, and dental impressions. This evaluation will help determine if the patient meets the medical necessity criteria for braces.

4. Pre-Authorization: The orthodontist will submit a treatment plan along with the necessary documentation to Medicaid for pre-authorization. This documentation typically includes the evaluation findings, X-rays, and a justification for why the braces are medically necessary.

5. Approval Process: Medicaid will review the submitted documentation. If approved, Medicaid will authorize the orthodontic treatment. If not approved, the patient may appeal the decision or explore alternative options.

6. Treatment: Once approved, the patient can proceed with the orthodontic treatment, including the placement of braces.

 

Important Considerations

• Participating Providers: Ensure that your orthodontist is  Medicaid-approved provider. Not all providers accept Medicaid, so it's crucial to verify this beforehand.

• Follow-Up Visits: Orthodontic treatment requires regular follow-up visits for adjustments. These visits should be covered by Medicaid if the treatment has been approved.

• Coverage Limits: Be aware of any limitations or specific coverage details under Medicaid, which can vary. For example, there might be age limits or specific conditions that must be met.

​

Additional Resources

• New York State Medicaid Program: For more detailed information and to find participating providers, you can visit the New York State Medicaid website.

• Local Medicaid Office: Contact your local Medicaid office for assistance and to confirm details specific to your case.

• Orthodontic Providers: Speak directly with orthodontic providers who accept Medicaid to understand their process and requirements.

 

Following these steps and ensuring all documentation is thorough can help New York residents access necessary orthodontic treatment through Medicaid.