Does Dental Insurance Cover Braces?
The situation: The orthodontist quoted $5,500 for my daughter's braces. Will our dental insurance pay for it?
Quick Answer
Sometimes, partly. The NAIC says orthodontics, meaning braces and retainers, are generally covered through a rider, often at a lower percentage than other dental work. Many plans cover children's braces up to a lifetime maximum and cover adults less often. Under the ACA, dental coverage is an essential health benefit for children, not adults.
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What Happened
The Ortizes' dental plan has an orthodontic rider that pays 50% of braces for children, up to a $1,500 lifetime maximum. Their daughter's treatment costs $5,500, so the plan pays $1,500 over the course of treatment and the family pays $4,000, part of it from a flexible spending account. When her father asks about adult aligners, the plan says its orthodontic rider covers dependents under 19 only.
Likely Relevant Policies
- Dental insurance with an orthodontic rider
- Marketplace pediatric dental coverage
Potential Coverages
Orthodontic rider Medium likelihood
The NAIC says braces and retainers are generally covered through a rider, often at a lower percentage or copay.
Pediatric dental essential health benefit Possible likelihood
Dental coverage is an essential health benefit for children; whether it includes braces often depends on medical necessity rules.
Adult orthodontic coverage Low likelihood
Many plans limit orthodontic benefits to children, or cover adults at lower amounts.
Possible Exclusions
- Braces for purely cosmetic reasons, on some plans
- Adults, on plans that limit orthodontics to dependents
- Treatment that started before coverage began
Questions That Determine Coverage
- Does your plan include an orthodontic rider?
- What is the orthodontic lifetime maximum and percentage paid?
- Is there an age limit or waiting period?
- Does the plan require pre-approval?
Recommended Immediate Actions
- Ask the orthodontist for a treatment plan and cost breakdown.
- Ask the plan for a predetermination before treatment starts.
- Check whether an FSA or HSA can pay the rest.
Documents to Collect
- Orthodontist's treatment plan
- Your dental plan's orthodontic terms
- Predetermination letter
Common Claim Process
The orthodontist usually sends a predetermination to the plan. Plans often pay the orthodontic benefit in installments over the treatment period, until the lifetime maximum is reached.
Potential Outcomes
- The plan pays a percentage up to its lifetime maximum.
- The plan pays nothing for adult braces.
- Treatment is denied as not medically necessary under a pediatric benefit.
Risk Prevention Tips
- Check for an orthodontic waiting period well before treatment.
- Compare the lifetime maximum to typical treatment costs.
Frequently Asked Questions
Does dental insurance cover braces for adults?
Less often than for children. Many orthodontic riders cover dependents only, or pay a lower maximum for adults.
What is an orthodontic lifetime maximum?
The most a plan pays for orthodontic treatment per person over their lifetime, often much less than the full cost of braces.
Is children's dental coverage required?
Under the ACA, dental coverage is an essential health benefit for children, and it must be available, though you don't have to buy it.
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The factual claims on this page were checked against these sources. Rules and figures change, so check the source itself if you need to confirm the current version.
- Understanding your dental insurance: from cavities to cosmeticNational Association of Insurance Commissioners (NAIC)
- Dental coverage in the Health Insurance MarketplaceHealthCare.gov (Centers for Medicare & Medicaid Services)
Educational information, not advice: This page describes how dental coverage generally works, not how your plan will decide a claim. Check your plan's documents. This is educational, not dental or legal advice.