Obama Care, formally known as the Affordable Care Act (ACA), has expanded health insurance coverage for millions of Americans since it was enacted in 2010. One common question many parents have is whether orthodontic treatment like braces is covered under Obama Care insurance plans. In this comprehensive guide, we will examine whether braces and other orthodontic treatments are covered, what plans and programs may provide coverage, costs and affordability considerations, and tips for finding orthodontic coverage.
Do Obama Care Health Plans Cover Braces?
Unfortunately, the answer is generally no – traditional Obama Care plans usually do not cover braces or other orthodontic treatments. There are a few reasons for this:
- Braces are considered a cosmetic treatment rather than medically necessary. Obama Care plans tend to only cover basic dental care like cleanings, fillings, and extractions.
- Orthodontic coverage was intentionally left out of the Affordable Care Act requirements for marketplace insurance plans. Dental and vision care for adults are considered “essential health benefits” that plans may choose to cover, but are not required.
- Adding extensive dental or orthodontic coverage would increase premiums for medical plans under the ACA. Keeping these premiums affordable was a key goal of the legislation.
So for most standard Obama Care policies like Bronze, Silver, Gold, and Platinum plans, braces and other orthodontics like retainers or aligners will not be covered. There are some exceptions we will discuss below, but generally families will need to pay for braces out-of-pocket or through a separate dental insurance plan.
Obama Care Plans That May Cover Braces
While orthodontic coverage is not required or typical, there are some Obama Care plans that may include braces or options to add this coverage:
Plans Offering Optional Dental Coverage
Some medical insurance companies that provide Obama Care marketplace plans may offer optional supplemental dental insurance plans to add on. These may cover a portion of orthodontic treatment costs like braces. For example:
- Blue Cross Blue Shield offers supplemental plans covering pediatric dental services, including braces, in some states where they provide marketplace exchange plans.
- UnitedHealthcare has a supplemental Enhanced Dental Benefit that can be added to plans in some states that covers braces for under 19 year olds.
- Kaiser Permanente, another major Obama Care insurer, has pediatric dental options to add to plans in regions they serve covering braces.
If dental coverage is offered, it usually comes at an additional monthly premium of $20-50 per month. This supplemental insurance may cover 30%-60% of total orthodontic costs, up to annual limits like $1500-$2000.
Plans in States Requiring Orthodontic Coverage
A handful of states have gone beyond the ACA to require insurers in their marketplaces to include pediatric dental coverage:
- Washington
- Nevada
- Connecticut
- New York
- Vermont
- Kentucky
- California
- Massachusetts
- Rhode Island
In these states, Obama Care medical plans must cover braces and orthodontia for children, sometimes up to age 19 or 21. Coverage levels vary by state from 50% to 85% of costs. So if you live in one of these states, check with your insurer to see what orthodontic services are included.
Obama Care Dental Savings Plans
Another option some states offer are dental savings plans created under the ACA. These are discount plans to reduce costs for services like braces using the state marketplace infrastructure. For example, the state of Washington offers Pacific Dental Services plans with negotiated savings with orthodontists. These are not full dental insurance, but may cover 20%-60% of brace costs.
Medicaid & CHIP Coverage for Braces
Medicaid provides free or low-cost health coverage to millions of low-income individuals and families. The Children’s Health Insurance Program (CHIP) also gives health insurance specifically to children in families who earn too much for Medicaid but can’t afford private health coverage.
Do these programs cover braces? It depends on your state’s policies:
- Some states include braces and orthodontic care in standard Medicaid dental benefits for children. States like Arizona, California, Massachusetts, and New York include braces.
- Other states only cover braces under Medicaid when medically necessary and with pre-approval. Orthodontia may be approved if very crooked teeth or jaw alignment issues cause speech impediments or difficulty eating.
- A number of states exclude braces from standard Medicaid dental coverage for children. These include Florida, Illinois, Texas, Pennsylvania, and more. Families may need to seek other options.
- For CHIP programs, each state sets its own guidelines. Many align with Medicaid, while others are more generous – some CHIP programs offer braces as a standard benefit.
Bottom line – eligibility for Medicaid or CHIP orthodontic coverage depends entirely on your state’s policies. Check with your state Medicaid or CHIP program to find out if braces are covered either generally or on a medical necessity basis.
Braces Coverage for Federal Employees
If you or a family member has health insurance through a federal government employee plan like the Federal Employee Dental and Vision Insurance Program (FEDVIP), braces may be covered for children under age 19.
Coverage levels and costs vary between the 10-15 FEDVIP dental carriers, but many plans cover 50% of orthodontic costs up to a lifetime limit, such as $2,000 per child. This can significantly offset the total price of braces.
Using an FSA, HSA, or HRA for Braces
Several types of tax-advantaged accounts can also help pay orthodontic costs:
Flexible Spending Account (FSA)
A healthcare FSA lets you set aside pre-tax dollars from your paycheck to pay for medical expenses. Depending on your employer’s plan, orthodontic care like braces is generally eligible, up to annual limits around $2750. FSA funds must be used in the same year, but you could plan to use an FSA to pay part of the cost of a new set of braces each year.
Health Savings Account (HSA)
If you have a high-deductible health plan, you may have access to an HSA account. Like an FSA, you can use HSA funds to pay for braces tax-free. The balance rolls over if unused each year, so you could save up towards orthodontic costs over several years.
Health Reimbursement Arrangement (HRA)
Employers may offer an HRA account with company contributions to reimburse medical expenses tax-free, including braces. Only unused funds roll over each year with an HRA, but it can help pay orthodontic costs.
Out of Pocket Braces Costs
What is the typical cost for braces if you are paying out-of-pocket without insurance? On average, according to the American Dental Association, average costs in 2022 were:
- Metal Braces (children): $3,000 – $7,500
- Metal Braces (adults): $4,000 – $9,500
- Ceramic Braces: $3,500 – $8,500
- Clear Aligners (Invisalign): $3,500 – $8,000
Factors like the type of braces, extent of needed alignment, your geographic location, orthodontist experience levels, and extra costs for retainers or extraction can all impact total fees. Many orthodontists offer no-interest monthly payment plans to make costs more budget-friendly. Overall costs have increased about 3%-5% annually in recent years.
Some additional options to reduce out-of-pocket braces costs include:
- Dental schools – orthodontic work done by dental students overseen by faculty is 30%-60% less.
- Dental tourism – traveling abroad to get braces done in countries like Mexico or Costa Rica can mean savings of 40% or more.
- Orthodontic insurance – discounted plans with monthly fees to reduce total costs may be an option.
Tips for Getting Braces Covered
If braces aren’t covered under your standard health or dental plan, here are some tips to explore coverage:
Check your state’s Obama Care policies
As mentioned above, some states require orthodontic coverage for children on marketplace plans. If yours is one, take advantage of this benefit.
Ask about supplemental dental options
Even if your core health plan excludes braces, you may be able to add pediatric dental coverage separately for a small monthly fee, so always ask.
Look into discounts and payment plans
Many orthodontists work with patients on costs by offering no-interest payment plans over 1-3 years. Payment plans allow you to spread costs over time interest-free.
Use tax-advantaged accounts
An FSA, HSA, or HRA allows you to pay for braces with pre-tax dollars and save 20%-30% on costs.
Seek multiple orthodontist opinions
Consultations are often low cost or free. Compare quotes among 2-3 practices to find the best combination of price, expertise, and payment options.
Conclusion
While standard Obama Care health plans do not include orthodontic coverage, options exist in some states and plans to get partial coverage or discounts for braces for children. Using supplemental dental plans, tax-savings accounts, orthodontist discounts and payment plans, and shopping around can help offset the costs of braces. For adults, options are more limited, but negotiating with orthodontists and shopping around remains important.