Does CHIP Cover Braces in PA? Salzmann Score and Prior Authorization

Pennsylvania’s Children’s Health Insurance Program does cover braces, but only when an orthodontist documents that the treatment is medically necessary under state rules, not cosmetic. So the honest answer to does CHIP cover braces in PA is yes with conditions: your child’s case has to meet specific clinical criteria, score high enough on a standardized evaluation, and get prior authorization from your CHIP insurer before any brackets go on.

What Has to Be Wrong for CHIP to Pay

Pennsylvania regulation 55 Pa. Code § 1149.55 lists the orthodontic problems that qualify. Braces are covered when they prevent irreversible damage to the teeth or supporting bone, or when they correct serious problems in one of four categories.¹

Jaw or facial abnormalities: a severely protruding upper or lower jaw, a significantly underdeveloped lower jaw, noticeable facial asymmetry, or upper and lower teeth that protrude so far the lips cannot close.
Eating difficulties: a bite misalignment so severe the child needs a liquid or soft diet, experiences jaw-joint pain while eating, or must use exaggerated facial movements to chew.
Breathing problems: chronic mouth breathing, postural issues like a forward-extended head, or other breathing difficulties directly caused by the misalignment.
Speech impairments: lisping or other speech errors directly tied to the shape or position of the jaw and teeth.

Minor crowding, small gaps, or a mildly uneven smile do not meet the threshold. The program is built around structural problems that interfere with eating, breathing, speaking, or long-term dental health, not appearance.¹

The Salzmann Score Requirement

Clinical categories alone are not enough. Your child must also score 25 or higher on the Salzmann Evaluation Index.¹ The Salzmann Index is a standardized scoring tool that assigns points based on physical measurements: how far teeth are displaced, the degree of overbite or underbite, whether teeth are impacted or rotated. A higher score signals a more severe problem.

The orthodontist calculates the score during the initial exam and submits it to the insurer along with panoramic and cephalometric X-rays, clinical photographs, and supporting notes. Before the file goes out the door, ask the orthodontist’s office to confirm the Salzmann assessment is complete and the measurements are documented. An incomplete score can stall or sink the approval.

Prior Authorization Before Treatment Begins

Braces require prior authorization. The orthodontist cannot start treatment and bill CHIP after the fact.² Once the evaluation is complete, the office submits the documentation to your child’s CHIP insurer. A clinical reviewer examines everything against the Department of Human Services’ medical necessity guidelines. If that reviewer cannot approve the request, it moves to a physician for a second-level review.³

You and the provider both receive a written decision. If it is a denial, the notice has to spell out why. If it is an approval, the orthodontist can start under the terms the insurer specifies.

Using an In-Network Orthodontist

Orthodontic benefits only apply when the provider participates in your child’s specific CHIP plan. Call your insurer’s member services line before scheduling an evaluation and confirm the orthodontist is in-network for that plan. A dentist or orthodontist who accepts Medicaid does not necessarily participate in CHIP managed-care networks, and seeing an out-of-network provider usually means the claim gets denied.

If the orthodontist you want is only in-network with a different CHIP insurer that serves your county, you can switch. Call CHIP at 1-800-986-5437 to request a transfer.⁴ The list of CHIP insurance companies and which ones operate in your county is maintained by the Commonwealth.⁵

What Your Family Will Pay

Cost depends on your household income relative to the federal poverty level (FPL). Pennsylvania divides CHIP into three tiers.⁶

Free CHIP, for families earning up to 208% of FPL: no monthly premium, and medically necessary orthodontic treatment is covered at no cost.
Low-Cost CHIP, for families between 208% and 314% of FPL: a monthly premium that varies by insurer and county, with possible office-visit copayments.
Full-Cost CHIP, for families above 314% of FPL: the full premium, also varying by insurer and county.

As of early 2026, Low-Cost premiums generally start around $50 and can reach roughly $80 per child, while Full-Cost premiums can run close to $200 per child per month.⁷ Some insurers price below the published rates, so call each CHIP company available in your county to compare. There is no annual dollar limit on dental services or medically necessary orthodontic care under any CHIP tier.⁶

If the insurer determines the braces are cosmetic rather than medically necessary, CHIP pays nothing. Metal braces without insurance typically run $3,000 to $7,000 out of pocket.

Retainers and Replacements

CHIP covers orthodontic retainers with prior authorization, the same way it covers braces.² What it does not cover is replacement or repair. The benefits handbook explicitly excludes:

Repair of damaged orthodontic appliances
Replacement of lost or missing appliances
Removable orthodontic retainer adjustments

If your child loses or breaks a retainer, you pay full price.⁶ A single replacement retainer typically costs between $100 and $500 depending on the type. Since retainers keep teeth from drifting back after braces come off, plan for that possibility from the start.

Age Limits and Aging Out Mid-Treatment

CHIP covers children under 19. Coverage ends the last day of the calendar month in which the child turns 19, with no exceptions.⁶ The orthodontic rule also requires that the child have a fully erupted set of permanent teeth before treatment starts.¹ Most children don’t get there until age 11 or 12, and orthodontic treatment typically runs 18 to 30 months, so the window matters. Start too late and the child ages out before the braces come off.

When a child does turn 19, the Department of Human Services screens them for Medical Assistance eligibility.⁶ If they qualify for MA and were already receiving orthodontic services through a state program, coverage can continue for recipients age 21 or younger.¹ If they don’t qualify, the remaining treatment is on the family. The federal InsureKidsNow program advises parents to settle this with the orthodontist up front: what happens financially if the child loses coverage before the braces are off?² A contingency payment plan written into the treatment agreement is cheaper than a surprise bill later.

If the Insurer Denies Coverage

A denial is not the end of the road. You can challenge it, and you do not need a lawyer to start.

Grievance: within 60 days of the denial letter, file a formal request asking the insurer to reconsider the medical necessity decision. You can file by phone, in writing, or by fax. The grievance panel must issue a written decision within 30 days, or within 72 hours if you request an expedited review based on your child’s health.⁸
External review: if the grievance still goes against you, request an external review within 15 days. An independent reviewer not affiliated with the insurer examines the full record.⁸
Fair hearing: within 120 days of the grievance decision, request a state fair hearing before an administrative law judge. You can submit additional documentation and speak for yourself.

At any point in this process, you have the right to a second opinion from a qualified network provider at no cost. If no qualified in-network provider is available, the insurer has to arrange one out-of-network, still at no charge to you.⁸

1
Cornell Law Institute. 55 Pa. Code 1149.55 – Payment Conditions for Orthodontic Services
2
Insure Kids Now. Summary of Benefits Report for Pennsylvania, CHIP
3
Keystone First. Prior Authorization
4
Commonwealth of Pennsylvania. About Your Coverage FAQ
5
Commonwealth of Pennsylvania. CHIP Insurance Companies
6
PA.gov. CHIP Eligibility and Benefits Handbook
7
PA.gov. CHIP Contractor Rate Information
8
PA.gov. CHIP Procedures Handbook