Does Medicare Cover Braces?PolicyScout’s Guide To Braces And How Medicare Can Help Cover Them.
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Braces are used to fix your bite or straighten your teeth. They’re most often fitted to teenagers’ teeth when their jaws are still growing. However, over the past few decades, there’s been an increase in the number of adults with braces.
According to IBISWorld, around 4 million people in the U.S. have braces and 25% of those are adults. Braces also made up the majority of revenue for U.S. orthodontists, accounting for an estimated 47.7% of revenue in 2021.
This article will help you understand what braces are, how much they cost, and how Medicare can help cover them.
What Is Medicare?
Medicare is a U.S. federal health insurance program for people 65 or older, some younger people with disabilities, as well as people with End-Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS).
You can get Medicare coverage either through the government-run Original Medicare program, or you can get private coverage known as Medicare Advantage.
You Can Get Medicare Coverage in Different Ways
Medicare Part A refers to inpatient treatment and hospital care, including hospital stays, hospital treatments, and general nursing costs.
Medicare Part B relates to outpatient medical coverage and includes preventive treatments, doctors’ consultations, scans, and tests.
Medicare Advantage Plans
Part C/Medicare Advantage Plans are health plans offered by insurance companies that have contracts with Medicare.
These policies cover Part A, B, and D expenses, including costs for hospital care, prescription drug coverage, and doctors’ visits.
Prescription Drug Plans (PDPs)
Stand-Alone Part D Plans (Prescription Drug Plans) cover self-administered prescription drugs. For example, medications for high blood pressure, pain tablets, and antidepressants.
Medicare Supplement Insurance
Medicare Supplement Insurance is a health plan for people who have Original Medicare that covers out-of-pocket costs such as deductibles, coinsurance, and co-payments.
What Are Braces?
Over time your teeth and bite position can change. This could complicate how you chew food or maintain oral hygiene.
Uneven spacing, poor alignment, or a problematic over/underbite can lead to dental problems such as breakage, decay, crowding, or crooked teeth. This is where braces can help.
Braces are dental tools that correct either an over or underbite or straighten teeth. As you wear braces, your teeth will slowly straighten and align so that you have a normal bite.
Braces are typically used for teenagers, but adults can use them too. These days there are many more options available to you than there were when you were a child.
These are the most common types of braces:
Conventional braces help reposition your bite by attaching metal or ceramic brackets to each tooth so that they can hold a wire and bands that help realign your teeth.
Metal braces are the oldest and most common type of orthodontic treatment.
They are also the cheapest and fastest form of realignment. However, one of the cons is the high visibility of the metal brackets and wires.
Conventional braces are also offered as ceramic brackets. These are colored brackets intended to blend in with teeth color.
The ceramic brackets, though, are more brittle than metal and also tend to stain without proper care.
These braces look and function similarly to their conventional counterparts. However, there are no bands required in the adjustment process.
This is because of the clip-style brackets used that allow the wire itself to be tightened.
These braces are installed behind the teeth which make them practically invisible.
These braces function similarly to conventional ones but they are significantly more expensive. This is because of their installment and adjustment difficulty.
Most commonly, aligners, also referred to as Invisalign, are customized clear plastic molds that fit over the teeth.
This option eliminates the need for conventional braces by realigning the position of your teeth through stages that require a new set of molds every few weeks.
If you are using aligners, you will wear each mold for a set period of time before swapping them for a straighter mold as the teeth shift.
This is the most comfortable option for braces as the patient can remove and replace them at will. The disadvantage, however, is how slow the teeth realignment happens compared to conventional braces.
Wearing aligners may also not be an option in cases of severe misalignment.
Does Medicare Cover Braces?
Most dental care is not typically covered by Medicare, but you may be able to find coverage through a private health insurance policy.
You can get braces through Medicare; however, this is only in the event of severe cases causing major health concerns.
Original Medicare (Parts A and B) typically doesn’t have benefits that cover braces. However, if an accident or disease makes a restorative orthodontic procedure necessary, it is then possible to have them covered.
If Original Medicare considers the braces medically necessary it will provide coverage.
If the orthodontic procedure is an emergency, or surgery that requires a hospital stay is needed, Medicare Part A could help cover the associated hospital costs.
Although Original Medicare offers very limited dental or orthodontic coverage, you may be able to find a coverage alternative through a Medicare Advantage Plan.
Medicare Advantage Plans provide everything that Original Medicare offers, but they also include additional benefits like vision, hearing, and dental care.
Because Medicare Advantage Plans are offered by private insurance companies, the packages available through these plans differ.
Some plans may cover routine dental care, but exclude specialist care like braces. This means that it’s crucial that you check with your provider before going in for treatment.
Check the list of benefits provided by each insurer to understand your options and any related cost-sharing like co-payments, deductibles, and limits.
Terms You Should Know
Premium: A recurring payment to your Medicare, Medicare Supplement, or Medicare Advantage program for continued coverage.
Coinsurance: Your share of the costs of a covered health care service. The amount is calculated as a percentage of the allowed amount for the service.
For example, if your coinsurance is 20%, you would pay 20% and Medicare takes care of the other 80%.
Co-payment (Co-pay): The amount that you may be required to pay as your share of the cost for a medical service or supply. A co-payment, or co-pay, is usually a set amount rather than a percentage.
For example, you might pay $10 for a doctor's visit or prescription. In Original Medicare, co-payments are also used for some hospital outpatient services. For more information on Co-insurance vs. Copay check out our article here.
Deductible: The amount that you must pay for health care or prescriptions before Original Medicare, a prescription drug plan, or your other health insurance begins to pay.
In Original Medicare, you are required to pay a deductible for each new benefit period for Part A and for each year for Part B.
How Can I Get Medicare to Cover Braces?
Original Medicare does not cover dental services, which includes braces.
Medicare excludes all dental services, with some specified situations at times being an exception.
For example, if dentistry or oral surgery is required for the policyholder, then a broader plan of Medicare will provide coverage.
However, Medicare Advantage and/or stand-alone-private dental insurance plans can help cover dental services like braces. These policies may not fully cover these expenses but will lower your out-of-pocket costs.
To get some coverage for these costs, you will need to enroll in Medicare Advantage or get a private dental insurance plan.
Four Categories of Medicare Advantage Plans
Health Maintenance Organization (HMO) plans cover care from in-network providers, with particular exceptions that include emergency services.
Preferred Provider Organization (PPO) plans allow you to see any provider, but in-network providers tend to cost significantly less.
Private Fee-For-Service (PFFS) plans let you see any provider that accepts the terms of the plan. Some plans have networks that include providers who fit into this category.
Special Needs Plans (SNPs) require you to use in-network providers. They typically have specialists with expertise in the condition(s) that affect you.
Braces Coverage through Medicare Advantage Plans
Original Medicare (Part A and Part B) does not cover braces and that is why Medicare Advantage Plans are the most common alternative.
Medicare Advantage Plans provide a way for people to get coverage for dental procedures. Medicare Advantage typically covers:
Because Medicare Advantage Plans are sold through private insurers, the coverage is determined by the policy.
Medicare Advantage Plans may be able to provide braces coverage if your specific plan offers dental coverage. This provision could include any kind of braces. If you are unsure then you should call your insurance provider to find out.
How Much Do Braces Cost?
On average, braces can cost anywhere between $3,000 - $10,000.
However, the price may vary based on factors such as:
Where you live
Although it might seem odd, the place you live can affect the price of your braces. Different states may have different prices because of their available level of expertise or how common brace fitting is.
Your age will also impact the price of your braces. Typically, younger children or teenagers can get braces cheaper than adults can.
How much adjustment do your teeth need
The type of braces you get depends on how much your teeth need to be realigned or fixed. If your teeth are straight and you are just looking for a small fix, then your costs will be cheaper than someone needing substantial changes.
If the amount of adjustment you need involves more work and complexity, it will be more expensive.
The type of braces you get
With different types of braces available that each offers different levels of adjustment and visibility, the cost for them will vary.
For example, conventional braces, which are the most visible but highly effective, are cheaper than lingual braces that are less visible, but more difficult to insert.
The amount of time you need braces
The reason why you need braces and the amount of time you need them will impact your costs.
If you have braces for longer, it will require more checkups and more maintenance costs.
The expertise of your orthodontist
The level of skill that your orthodontist offers will also affect how much you pay. If you use a highly-skilled, popular orthodontist, you will likely pay more than you would for a lesser skilled surgeon.
Damages to the braces
Braces can also get damaged. This can result from hard food or poor maintenance. If your braces get damaged, for example, a broken bracket, then you will have to cover the costs of the repair or checkups.
The cost of braces will also depend on the type of braces you get. Here are some examples of what you might expect to pay:
Prices of Different Braces
Standard Metal Braces - $3,000 to $7,500
Ceramic Braces - $2,000 to $8,500
Invisalign Braces - $3,000 to $7,000
Lingual Braces - $5,000 to $13,000
Learn About Medicare Coverage:
If you want to learn about what Medicare covers, be sure to read our latest articles:
Where Can I Learn More about Medicare?
If you have Original Medicare and dental coverage is something that you think you are going to need, specifically for braces, perhaps switching to a Medicare Advantage Plan or private insurer could be a better option for you.
If you want to learn more about Original Medicare, Medicare Advantage Plans, or anything Medicare-related, head to PolicyScout’s Medicare hub to compare your options and find the best plan in your area.
If you are looking for personalized guidance, send your questions to Help@PolicyScout.com or call us at 1-888-912-2132 to get assistance from one of our skilled Medicare consultants.