Does Dental Insurance Cover Orthodontics? Kids and Adults

Many dental insurance plans cover part of orthodontic treatment, usually a percentage of the fee or a fixed benefit amount, often capped by a lifetime maximum. The AAO says coverage can vary significantly between policies, and that contacting your insurance provider can help you determine any age limits and whether your orthodontist needs to be in-network (AAO). At Bloom, our team verifies your benefits before your first appointment (insurance and financing).

We accept most PPO orthodontic insurance plans at our Long Beach and Garden Grove offices. Below is how orthodontic benefits usually work, how the rules differ for kids and adults, and what to ask your plan.

How Orthodontic Benefits Usually Work

The American Association of Orthodontists (AAO) says insurance for orthodontic treatment is intended to cover a portion of the fee, and you pay the remainder. Most benefits follow the same pattern.

A percentage or a fixed amount. The plan pays a share of the treatment fee or a set dollar benefit.
A lifetime maximum. The AAO lists lifetime maximums among the limits to confirm with your insurer.
Age limits. The AAO also lists age limits for orthodontic coverage among the things to check.
Network rules. The AAO suggests checking whether your orthodontist needs to be in network.
Pre-authorization. The AAO suggests asking your insurer about pre-authorization requirements, and Delta Dental notes that pre-authorizations or referrals are required for certain Delta Dental benefit plans.

The AAO also notes that insurance is optional for orthodontic treatment. Payment plans and FSA or HSA funds are other ways to pay.

Kids and Teens vs Adults

Children and teens. HealthCare.gov says dental coverage is an essential health benefit for children 18 and under, so it must be available for a child getting Marketplace health coverage. In California, Covered California includes dental insurance for children under 19 with every health plan at no extra monthly cost. On the family dental plans Covered California sells, medically necessary braces are listed for children only, at $350 on a dental HMO, and you pay 50 percent on a dental PPO.

Medi-Cal. The California Department of Health Care Services says Medi-Cal Dental covers medically necessary services for members under 21, and orthodontic requests are judged against handicapping malocclusion criteria. The state uses a scoring sheet called the Handicapping Labio-Lingual Deviation (HLD) Index. A score of 26 or more, or one of six automatic qualifying conditions, meets those criteria. The orthodontist submits a Treatment Authorization Request for review.

Bloom does not accept Medi-Cal. If Medi-Cal denies a patient because they do not qualify on the HLD form, Bloom can still treat them in the office with in-house payment plans.

Adults. HealthCare.gov says dental coverage is an essential health benefit for children only, and health plans can leave out adult dental coverage, so adult orthodontic coverage depends on your specific plan. Bloom's adult orthodontics page notes that many dental insurance plans cover adult orthodontics, and Bloom's clear aligner cost guide notes that some plans have age limits for adults.

PPO vs HMO Dental Plans

The type of plan changes which orthodontist you can see.

	Dental PPO	Dental HMO (DHMO)
Choice of dentist	In network and out of network	In network only, except emergencies
Specialist referral	Not needed	Needed from your primary dentist
How costs work	You pay a share, often with a deductible	Set copays, usually no deductible

Table source: Covered California's dental plan comparison. Bloom accepts most PPO orthodontic insurance plans. If you are unsure about your plan, call us and we will check it for you.

Are Clear Aligners and Lingual Braces Covered?

Often, yes. Bloom's clear aligners page notes that many dental insurance plans cover clear aligners the same as traditional braces, and Bloom's lingual and clear braces pages note that many plans cover a portion of treatment. Your plan decides the exact amount, and we confirm it before you start.

Using Insurance With an FSA or HSA

Insurance and pre-tax accounts work together. Orthodontic treatment is an eligible expense under most Flexible Spending Accounts and Health Savings Accounts, and IRS Publication 502 lists braces among the dental treatments you can include in medical expenses. Many patients use FSA or HSA funds for the part insurance does not pay.

Watch the calendar with an FSA. The AAO notes that FSAs typically have a use-it-or-lose-it policy within the calendar year, so check your plan's deadline.

Checking Your Plan

Questions to ask

Does my plan include orthodontic benefits for me or my child?
What percentage or fixed amount does it pay?
What is the orthodontic lifetime maximum, and is it separate from the yearly dental maximum?
Is there an age limit or a waiting period?
Do I need pre-authorization or a referral?
Does the orthodontist need to be in network?
If I change plans during treatment, what happens to my benefit?
If my child has Medi-Cal Dental, does this orthodontic office accept it?

You can also skip the phone call. Our team verifies your benefits before your first appointment so you know what to expect. Dr. Thao Nguyen Vu and Dr. Judy Nguyen are board-certified orthodontists, and they review your plan options with you at the free consultation.

Frequently Asked Questions

Does dental insurance cover braces?

Many plans cover part of the cost, usually a percentage or a fixed benefit, often up to a lifetime maximum. Coverage depends on your plan, your age, and your network. Bloom accepts most PPO orthodontic insurance plans and verifies your benefits before your first appointment.

Does insurance cover braces for adults?

Sometimes. Under Marketplace rules, dental coverage is an essential health benefit for children only, so adult coverage depends on your plan. Many dental plans cover adult orthodontics, and some set age limits for adults. Our team can verify your benefits before your first appointment.

Does insurance cover clear aligners?

Many dental insurance plans cover clear aligners the same as traditional braces. Your plan sets the amount, and we confirm it before treatment starts.

What is an orthodontic lifetime maximum?

It is the total amount a plan will pay toward orthodontic care over your lifetime. Once the plan reaches that amount, you pay the rest, often with a payment plan or FSA or HSA funds.

Does Medi-Cal cover braces?

Medi-Cal Dental covers medically necessary orthodontic treatment for members under 21, judged by a state scoring sheet called the HLD Index or by one of six automatic qualifying conditions. The orthodontist submits a Treatment Authorization Request for review. Bloom does not accept Medi-Cal, but if Medi-Cal denies a patient on the HLD form, we can still treat them in the office with in-house payment plans.

Do I need insurance to get braces?

No. The AAO notes that insurance is optional for orthodontic treatment. Bloom offers low and no-interest payment plans, and orthodontic treatment is an eligible FSA and HSA expense under most plans.

Does Bloom take my insurance?

We accept most PPO orthodontic insurance plans. Call either office and we will check your plan for you.

Sources

American Association of Orthodontists, How Much Do Braces Cost?
American Association of Orthodontists, Payment and Insurance FAQs
American Association of Orthodontists, How to Save for Orthodontic Care
HealthCare.gov, Dental coverage in the Marketplace
Covered California, Dental Insurance
California Department of Health Care Services, Medi-Cal Dental EPSDT Services
California Department of Social Services, Medi-Cal scope of benefits, general and dental
Delta Dental, Dental HMO vs PPO
Internal Revenue Service, Publication 502, Medical and Dental Expenses
Bloom: Insurance and financing, Clear aligners, Lingual braces, Clear braces

Want to know what your plan covers? Book a free consultation and our team will verify your benefits. For fees by treatment, see how much braces cost in Long Beach and Garden Grove.

DoesDentalInsuranceCoverOrthodontics?KidsandAdults