Virginia Medicaid does cover braces, but only for enrolled children and young adults under 21 whose malocclusion is severe enough to qualify as medically necessary. Cosmetic cases are not covered, and adults 21 and older are excluded from orthodontic benefits entirely. To get braces paid for, the patient generally has to score at least 25 points on the Salzmann Malocclusion Severity Assessment or meet one of the state’s listed handicapping conditions, and an in-network orthodontist has to submit a prior authorization request to DentaQuest, which administers the state’s Cardinal Care Smiles dental program.
Who Qualifies by Age and Program
Orthodontic coverage sits inside the federal Early and Periodic Screening, Diagnostic, and Treatment benefit, which obligates state Medicaid programs to provide all medically necessary services to members under 21.1Medicaid.gov. Early and Periodic Screening, Diagnostic, and Treatment In Virginia, that gives children enrolled in Medicaid or FAMIS (Family Access to Medical Insurance Security) a right to an orthodontic evaluation when a dental condition may impair their health. Benefits are delivered through Cardinal Care Smiles, managed by DentaQuest.2Department of Medical Assistance Services. Dental – Adults – Virginia Medicaid
Once a member turns 21, orthodontic coverage ends. Virginia’s adult dental program explicitly excludes orthodontia, even for pregnant women who otherwise receive comprehensive dental benefits.3DentaQuest LLC (Administering Virginia Medicaid’s Cardinal Care Smiles). Office Reference Manual – Cardinal Care Smiles – Virginia Medicaid Some oral surgery tied to trauma or structural abnormality may still be covered under medical benefits through Medicaid or a managed care organization, but that is separate from braces.
The child also needs to be enrolled. Virginia Medicaid for Children and FAMIS are income-based programs, with FAMIS reaching higher income levels than Medicaid; a family of four, for example, qualifies for Medicaid for Children with yearly income up to $48,840, and for FAMIS up to $67,650.4Virginia Department of Medical Assistance Services. Medicaid for Children and FAMIS – CoverVA Thresholds scale with household size, and families apply through CoverVA.
What Counts as Medically Necessary
Being enrolled and under 21 does not guarantee braces. Virginia pays for orthodontic treatment only when the patient has a severe, dysfunctional, handicapping malocclusion, and clinical reviewers use a two-step process to decide.3DentaQuest LLC (Administering Virginia Medicaid’s Cardinal Care Smiles). Office Reference Manual – Cardinal Care Smiles – Virginia Medicaid
First, the reviewer checks whether the condition meets any of the state’s listed handicapping criteria. These are specific conditions severe enough to approve without scoring, such as a deep overbite damaging the palate tissue or an anterior crossbite destroying soft tissue. If the case fits one of those categories, DentaQuest approves the request without further scoring.
If it doesn’t, the reviewer moves to the Salzmann Malocclusion Severity Assessment. The index assigns point values to problems including crowding, rotation, spacing, overbite, overjet, crossbite, and open bite across the front and back teeth. The patient must score at least 25 points, and no primary (baby) teeth can remain. Points are not awarded for cosmetic concerns. The assessment focuses on functional impairment: difficulty chewing, persistent pain, or speech problems caused by the physical alignment of the teeth or jaw.
Prior Authorization and Timing
An orthodontist enrolled in Virginia’s Medicaid dental network has to assemble the prior authorization request. You can find a participating provider through Cardinal Care Smiles by calling DentaQuest at 1-888-912-3456 or searching the online provider directory.2Department of Medical Assistance Services. Dental – Adults – Virginia Medicaid
The orthodontist submits the Orthodontic Criteria Index Form along with a complete series of intraoral photographs and supporting documentation establishing medical necessity.5Virginia Department of Medical Assistance Services. Office Reference Manual – Virginia Medicaid That typically includes panoramic and cephalometric X-rays with structural tracings, extraoral photographs, and medical records documenting functional problems such as breathing difficulty or trouble eating. Bring the child’s Medicaid ID card and any relevant medical records to the consultation.
Incomplete submissions are the most common reason for delays and denials. Missing photographs or thin documentation of functional impairment can sink a request no matter how severe the condition actually is. The case has to clearly show either that the 25-point Salzmann threshold has been met or that one of the automatic handicapping criteria applies.
As of January 1, 2026, Virginia Medicaid requires DentaQuest to decide standard prior authorization requests within 7 calendar days of receiving them.6Virginia Department of Medical Assistance Services. Interoperability and Prior Authorization Final Rule Implementation Update Urgent requests, where delay could seriously jeopardize health, must be decided within 72 hours. These timelines come from a federal CMS rule that took effect for state Medicaid agencies in 2026.7Centers for Medicare and Medicaid Services. CMS Interoperability and Prior Authorization Final Rule CMS-0057-F Families receive a Notice of Action letter with the determination. If approved, the notice specifies the authorized treatment duration and any follow-up requirements, and the member can schedule the banding appointment.
If the Request Is Denied
A denial can be appealed. Every Medicaid beneficiary has the right to a state fair hearing, and the denial notice itself must explain how to request one.8Medicaid.gov. Understanding Medicaid Fair Hearings In Virginia, you have 120 days from the date of the managed care organization’s final internal appeal decision to file for a state fair hearing with the DMAS Appeals Division.9Virginia Code Commission. Virginia Administrative Code 12VAC30-120-650 – Appeal Timeframes
Before the hearing, you can review the full case file the state used to make its decision. If you file the hearing request before the effective date of the denial, the state has to continue the child’s existing benefits until a final decision issues. Virginia must resolve the fair hearing within 90 days of the date the member originally filed the internal appeal with the managed care organization.9Virginia Code Commission. Virginia Administrative Code 12VAC30-120-650 – Appeal Timeframes An expedited hearing is available for urgent health care needs.
The most common reasons for denial are a Salzmann score below 25, missing documentation, and poor-quality photographs. When the denial turns on an incomplete submission rather than the merits of the condition, the orthodontist can often fix the deficiency and resubmit instead of running a formal appeal.
Retainers After the Braces Come Off
Virginia Medicaid covers retainers as part of full orthodontic treatment, but they need their own prior authorization. Replacement retainers require a narrative explaining the medical necessity for the replacement.10InsureKidsNow.gov. Summary of Benefits Report for Virginia Lost or broken retainers are common with younger patients, and a simple statement that the retainer was lost, without explaining ongoing clinical need, may not be enough. Keep records of any retainer issues and have the orthodontist document the clinical need at follow-up visits.
When Treatment Runs Past the 21st Birthday
Braces usually take 18 to 30 months. Patients who start at 19 or 20 risk aging out before the brackets come off. Federal EPSDT rules apply only to members under 21, and once a member crosses that line, they move to whatever adult benefit package the state offers.11Medicaid.gov. Best Practices for Adhering to Early and Periodic Screening, Diagnostic, and Treatment Virginia’s adult program excludes orthodontia.3DentaQuest LLC (Administering Virginia Medicaid’s Cardinal Care Smiles). Office Reference Manual – Cardinal Care Smiles – Virginia Medicaid
No clear federal or Virginia-specific rule guarantees that treatment will continue to completion once a patient turns 21. If a child is approaching that age and treatment isn’t finished, raise the timeline with the orthodontist and DentaQuest early. Traditional metal braces for an uninsured patient typically run $3,000 to $7,500 out of pocket, a bill most families are not prepared to pick up mid-treatment.