Across the country, it seems like orthodontic treatment has never been more popular. According to the American Association of Orthodontics, just under 4 million pediatric patients are currently undergoing orthodontic treatment, as are millions of adults. And itโs easy to see why.
After undergoing orthodontic treatment like Invisalign and conventional fixed braces, patients regularly report:
- A boost in personal appearance
- Higher confidence and self-esteem
- Better oral health
Given these advantages, it’s no surprise that more people than ever are looking into orthodontic care. Still, many prospective patients aren’t sure whether their insurance plan will cover treatment. At Beverly Hills Orthodontics, some of the most common coverage questions involve the California Medical Assistance Program, better known as Medi-Cal.
Designed to provide comprehensive coverage to Californians with low income, or no income, Medi-Cal currently covers more than 13 million people. As a comprehensive healthcare program, Medi-Cal is multifaceted and covers necessities such as personal care physician appointments, dental work, and hospitalizations. But what about orthodontics?ย
As with other insurance options, Medi-Cal users don’t always know what is and isn’t covered by their plan. In the orthodontist’s office, this leads to the following questions:
- Does Medi-Cal cover orthodontics?
- Which orthodontic problems are covered by Medi-Cal?
- Who is eligible to receive orthodontic care under the Medi-Cal program?
We’ll help you find the answers.
What Does Medi-Cal Cover?
Since 1965, Medi-Cal has provided Californians with a wide range of health services. Administered by the Department of Public Social Services, Medi-Cal’s benefits cover the following treatments:
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What Does Medi-Cal Cover? |
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Personal care physician visits |
Hospitalizations |
Pregnancy care |
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Dental appointments |
Preventative care |
Prescription medicines |
So, does Medi-Cal cover orthodontics? Beginning in February 1991, Medi-Cal expanded its dental program to include orthodontic care! However, there are very defined limits to what kind of care Medi-Cal will cover. Most importantly, Medi-Cal’s orthodontic program is restricted by both patient age and misalignment severity.ย
Does Medi-Cal Cover Braces?
Medi-Cal does cover braces if you meet certain specific (but common) conditions. Medi-Caql covers braces if:
They are medically necessary
Examples of medically necessary orthodontic conditions include severe misalignments, significant crowding, or dental issues that impact speaking or eating.
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When Does Medi-Cal Cover Braces? |
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You get prior authorization |
Medi-Cal requires extensive pre-treatment paperwork and documentation to be filled out by your orthodontist. You will need to get approval from Medi-Cal before you can begin any treatments. |
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You meet the age requirements |
Children and adolescents may have more extensive coverage for orthodontic treatment than adults, and there is a strict cut-off for anyone over 21. |
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Your orthodontist is in-network |
In order to use your Medi-Cal orthodontic benefits, you must receive orthodontic treatment from providers who participate in the program and are familiar with its requirements. |
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You’re prepared for out-of-pocket costs |
While Medi-Cal covers most orthodontic costs for eligible recipients, some out-of-pocket expenses, such as copayments or deductibles, may apply depending on the individual’s coverage. |
If your orthodontist agrees that you need medically necessary orthodontic treatment, but Medi-Cal denies your coverage, you have the right to appeal the decision. Make sure to keep excellent records and file the appeal within the required timeline!
Does Medi-Cal Cover Invisalign?
For several reasons, Invisalign is typically a bit more expensive than traditional metal braces. Regardless, if your Medi-Cal coverage would pay for braces, it usually will pay for part of your Invislaign treatment instead. Talk with your orthodontist and see if Invisalign aligners would be a good option for your orthodontic needs and what your specific Medi-Cal plan will cover.
Does Medi-Cal Cover Orthodontics? Yes! (With Limits)
While Medi-Cal does cover orthodontic work, not every type of treatment is included under the program. In addition, age limits leave many Medi-Cal patients ineligible for orthodontic coverage.
While we at BHO believe there’s never a wrong time to get orthodontic care and improve your smile, as of 2022, Medi-Cal orthodontic coverage is only available to patients under the age of 21, with no extensions allowed.
For patients under 21, Medi-Cal coverage is only available for issues considered “medically necessary” according to Title 22 of the California Code of Regulations. To paraphrase the language from Title 22 §51340.1, Medi-Cal covers treatments that will:
- Relieve pain
- Prevent infection
- Restore teeth
- Aid in maintaining dental health
- Correct physical defects
In accordance with these terms, six conditions automatically qualify for coverage under Medi-Cal. These conditions include:
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What Orthodontic Treatments Are Always Covered by Medi-Cal? |
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Cleft palate deformities |
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Craniofacial anomalies |
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Deep overbites that cause lower incisor teeth to damage soft palate tissue |
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Crossbites in which anterior teeth damage soft tissue |
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Severe overjets greater than 9mm |
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Severe traumatic deviation (e.g., bone/tissue loss caused by burns, physical trauma, etc.) |
If you or your child have these conditions, schedule an appointment with our office and inquire about Medi-Cal coverage for your treatment.ย
Beverly Hills Orthodontics Is Your Home for Medi-Cal Covered Orthodontic Treatment
If you qualify for realignment work, “Does Medi-Cal cover orthodontics?” is probably only the start of your questions. Here at Beverly Hills Orthodontics, we’re here to answer every question and provide top-notch care for our patients.
As a Blue Diamond Top 1% Invisalign practice, Beverly Hills Orthodontics is recognized as one of the top Invisalign providers in the country. Our founder, Dr. Monica Madan, uses both Invisalign and conventional braces to treat Medi-Cal-covered issues and create healthy, beautiful smiles. Call today to learn more!
Have more questions like “Does Medi-Cal cover orthodontics?” Call or text us at 310-785-0770 or visit our contact page to book an appointment.