Does Medi-Cal cover orthodontics?

The Medi-Cal Dental program’s benefits include orthodontic care for medically necessary conditions. Orthodontic benefits are from age 13 to 21. Eligibility for orthodontic coverage ends when the member reaches the age of 21, with no extended services allowed. Patients must maintain eligibility throughout the entire treatment.

If your orthodontist agrees that you need medically necessary orthodontic treatment, but Medi-Cal denies your coverage, you have the right to appeal the decision. Make sure to keep excellent records and file the appeal within the required timeline!

For patients under 21, Medi-Cal coverage is only available for issues considered “medically necessary” according to Title 22 of the California Code of Regulations. According to Title 22, §51340.1, Medi-Cal may cover treatments that will:

  • Relieve pain
  • Prevent infection
  • Restore teeth
  • Aid in maintaining dental health
  • Correct physical defects

In accordance with these terms, certain conditions automatically qualify for coverage under Medi-Cal. These conditions include:

  • Cleft palate deformities
  • Craniofacial anomalies
  • Deep overbites that cause lower incisor teeth to damage soft palate tissue
  • Crossbites in which anterior teeth damage soft tissue
  • Severe traumatic deviation (e.g., bone/tissue loss caused by burns, physical trauma, gross pathology, etc.)
  • Severe overjets greater than 9 mm

How does the Medi-cal approval process work?

At your child’s initial consultation we will complete a score sheet provided by Medi-cal Dental. If your child scores below 26 points on the score sheet or does not have one of the six automatic qualifying conditions, he/she will not be considered for treatment, and you will have the option of paying for any recommended treatment in full.

If your child scores 26 points or above on the score sheet or has one of the six automatic qualifying conditions, we will submit the necessary records to Medi-Cal Dental for approval. Such records may include one or more x-rays, models of the top and bottom teeth, and photographs. The cost for records is $200. After the records have been submitted to Medi-Cal, it may take up to 1-6 months to receive an authorization or denial of treatment.
If your child’s case has been reviewed by Medi-cal and approved, we will call you to schedule him/her for placement of the braces (or other appliances). At that time, we will refund the cost for records. Medi-Cal will only cover the records if your child’s case is approved. If you choose to proceed with the recommended treatment after receiving a denial, the $200 will be applied to your balance. You will not be reimbursed if your child’s case is denied by Medi-Cal AND you choose not to proceed with the recommended treatment.

While Medi-Cal covers most orthodontic costs for eligible recipients, some out-of-pocket expenses, such as copayments or deductibles, may apply depending on the individual’s coverage.

If you have questions about Medi-Cal coverage or want to schedule an appointment with our office, call us at 209-238-9800!