Virginia Medicaid does cover braces, but only for children and young adults under 21 whose misalignment is severe enough to qualify as medically necessary. Coverage runs through Cardinal Care Smiles, the dental benefit attached to Medicaid for Children, FAMIS, and FAMIS Plus, and is administered by DentaQuest.1Department of Medical Assistance Services. Dental – Virginia Medicaid Adults enrolled in Medicaid or FAMIS do not have orthodontic coverage.2Department of Medical Assistance Services. Smiles for Children Adult Dental Benefit Frequently Asked Questions When a child qualifies and treatment is approved, the family pays nothing.
Who Can Get Braces Through Medicaid
The child must be under 21 and actively enrolled in Medicaid for Children, FAMIS, or FAMIS Plus. Orthodontic coverage sits inside the federal EPSDT benefit, which requires Medicaid to cover medically necessary services for people under 21.3Department of Medical Assistance Services. Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) If you aren’t sure which program fits your household, the state publishes current income limits for Medicaid for Children and FAMIS.4Department of Medical Assistance Services. Medicaid for Children and FAMIS
A teenager who starts braces before turning 21 does not get cut off mid-treatment if coverage ends. DentaQuest will pay the remaining balance up to the approved case rate, with the provider submitting a final claim using the last date the patient was eligible.5Department of Medical Assistance Services. VA Smiles for Children ORM Latest Version 04242024
What “Medically Necessary” Actually Means
Virginia Medicaid will not pay for braces to fix crooked teeth that are only a cosmetic concern. The child must have a severe, dysfunctional, handicapping malocclusion. DentaQuest reviews each request first against specific handicapping malocclusion criteria, and if those are not met, through the Salzmann Malocclusion Severity Assessment. A child needs at least 25 points on the Salzmann Index to qualify on scoring alone.6Department of Medical Assistance Services. Office Reference Manual – Cardinal Care Smiles
Crowding by itself usually isn’t enough, even when it looks severe. Children whose molars and back teeth are already in good alignment rarely qualify, no matter how the front teeth look.7Department of Medical Assistance Services. Newly Enrolled Provider Training 2024 The question reviewers are asking is whether the bite creates a real functional problem.
A score below 25 isn’t automatically a denial. A child can still qualify by showing a documented functional impairment from the specific professional required for each type:7Department of Medical Assistance Services. Newly Enrolled Provider Training 2024
- A speech disorder documented by a physician or speech therapist.
- An eating disorder documented by a physician.
- Emotional or mental distress that impairs school participation, documented by a teacher, counselor, or school psychologist.
The letter has to come from the kind of professional listed. An orthodontist’s own statement that a child has trouble eating or speaking will not substitute.
What the Orthodontist Submits
Pre-authorization packages are detailed, and incomplete submissions are a common cause of delay. The orthodontist compiles the following for DentaQuest:6Department of Medical Assistance Services. Office Reference Manual – Cardinal Care Smiles
- Panoramic and cephalometric x-rays.
- A complete series of intra-oral photographs, plaster models, or digital models through OrthoCAD.
- Right profile, left profile, and frontal facial photographs.
- The Orthodontic Criteria Index Form.
- A treatment plan with a clinical narrative.
- Score sheets with all pertinent measurements, including overjet.
If intra-oral photos are used in place of models, they must include frontal views in occlusion, right and left buccal views, and upper and lower occlusal views. A significant overjet also calls for a low-angle frontal view. One missing image can bounce the whole package back for resubmission.
Finding a Provider and Getting Approved
Not every orthodontist takes Medicaid, so start with DentaQuest’s provider network. You can search online or call member services at 1-888-912-3456 to confirm a provider participates in Cardinal Care Smiles before scheduling.1Department of Medical Assistance Services. Dental – Virginia Medicaid
After the initial exam and diagnostic workup, the orthodontist sends the full pre-authorization package to DentaQuest. Once DentaQuest has complete documentation, a decision typically comes within two business days, and both the family and the provider get written notice.6Department of Medical Assistance Services. Office Reference Manual – Cardinal Care Smiles Missing paperwork lengthens the timeline because the provider has to gather what was left out and submit again.
What You Pay
Children enrolled in Medicaid or FAMIS have no premiums, copayments, or deductibles for covered services.4Department of Medical Assistance Services. Medicaid for Children and FAMIS When orthodontic treatment is approved, you owe nothing. Participating providers must accept Medicaid’s payment as payment in full and cannot bill you for any remaining balance.6Department of Medical Assistance Services. Office Reference Manual – Cardinal Care Smiles
One exception: if the orthodontist recommends something Medicaid does not cover, such as a premium bracket upgrade, they can charge you only if you agree in writing before the service is provided. You are never required to agree, and the covered treatment itself stays free.
If the Request Is Denied
A denial can be appealed. You have 30 days from the denial notice to file an appeal with DentaQuest, by mail to PO Box 2906, Milwaukee, WI 53201-2906, or by calling 1-888-912-3456 for help.8Department of Medical Assistance Services. Smiles for Children Office Reference Manual DentaQuest has 30 days to respond in writing, or 3 days when the child’s condition needs immediate attention.
You can also appeal directly to DMAS at the same time, after the DentaQuest decision, or instead of going through DentaQuest first. Written appeals go to the DMAS Appeals Division at 600 E. Broad Street, Richmond, Virginia 23219, or by fax to (804) 452-5454.8Department of Medical Assistance Services. Smiles for Children Office Reference Manual If DentaQuest upholds the denial on internal appeal, you can request a state fair hearing through DMAS; to keep benefits running during the hearing, you must file within 10 calendar days of the mail date on the final appeal decision.9Legal Information Institute. Virginia Administrative Code 12VAC30-120-640 – State Fair Hearing Process
The strongest appeals add clinical evidence the first submission didn’t have. A functional impairment letter from a physician, speech therapist, or school counselor documenting how the malocclusion affects your child’s daily life is often what turns a denial around.
Retainers and the Age-Out
Retainers after braces come off are part of covered treatment for children under 21. If a retainer is lost or broken, Medicaid may pay for one replacement per jaw over the child’s lifetime, with prior authorization and only when replacement is medically necessary.6Department of Medical Assistance Services. Office Reference Manual – Cardinal Care Smiles That is one upper and one lower replacement, total. A second lost retainer is on the family.