Does Medicaid cover braces in Texas in 2026? The answer depends on medical necessity and patient eligibility. As of today, Texas Medicaid does cover braces for children and teens under 21 through the Texas Health Steps (THSteps) program, but only if an orthodontist determines that the treatment is medically necessary. Adults over 21, however, are not covered for orthodontic services unless braces are part of a life-threatening or severe medical condition correction.
This guide provides a detailed look at how Medicaid coverage for braces works in Texas, including eligibility rules, covered treatments, the approval process, and the latest updates from the Texas Health and Human Services Commission (HHSC).
Table of Contents
Understanding Texas Medicaid and Orthodontic Coverage
Texas Medicaid is a joint federal and state program that provides healthcare coverage to low-income residents, including children, pregnant women, seniors, and individuals with disabilities. Within this system, dental and orthodontic benefits fall under Texas Health Steps (THSteps), also known as the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program.
For children under 21, THSteps ensures access to necessary preventive and corrective dental care, including orthodontics in qualifying cases. However, coverage is not automatic—orthodontic services like braces are approved only when they meet strict medical necessity guidelines set by HHSC.
Who Qualifies for Braces Under Texas Medicaid in 2026
Medicaid orthodontic benefits in Texas primarily apply to children and teens enrolled in the THSteps dental program. Adults do not typically qualify for Medicaid-covered braces unless the procedure is linked to a medically essential condition, such as correcting jaw deformities caused by trauma or congenital anomalies.
Eligibility Summary
| Age Group | Coverage for Braces | Conditions |
|---|---|---|
| Under 21 (Children/Teens) | Possible | Must be medically necessary under THSteps |
| 21 and Older (Adults) | Very limited | Only if braces are part of a covered surgical or medical treatment |
To be eligible for orthodontic coverage, the child must:
- Be enrolled in Texas Medicaid or the CHIP (Children’s Health Insurance Program).
- Have a referral from a Medicaid-approved dentist or orthodontist.
- Undergo an orthodontic evaluation proving that braces are medically required—not cosmetic.
What “Medically Necessary” Means for Medicaid Braces
For Medicaid to approve braces, the orthodontist must demonstrate that the patient’s condition affects their oral health, function, or overall well-being. Cosmetic or aesthetic concerns alone are not considered valid reasons for coverage.
Conditions That May Qualify as Medically Necessary Include:
- Severe overbite or underbite that affects chewing or speech.
- Crossbite causing jaw misalignment.
- Open bite or deep bite leading to tooth wear or pain.
- Congenital or developmental anomalies such as cleft palate or craniofacial disorders.
- Extreme crowding that results in gum or oral hygiene problems.
- Documented difficulty in eating, breathing, or speaking due to misalignment.
Orthodontists use a scoring system called the Handicapping Labio-Lingual Deviation (HLD) Index to determine eligibility. In Texas, a score of 26 points or higher typically qualifies a child for Medicaid-covered orthodontic treatment.
The Evaluation and Approval Process
Getting braces covered by Medicaid in Texas involves multiple steps, and approval is not guaranteed. The process is designed to verify medical necessity and ensure appropriate use of Medicaid funds.
Step 1: Referral and Initial Examination
A general dentist or pediatric dentist identifies the potential need for orthodontic treatment and refers the patient to a Medicaid-approved orthodontist.
Step 2: Orthodontic Assessment
The orthodontist conducts a full exam, including X-rays, photographs, and dental impressions, to evaluate the patient’s alignment and oral health.
Step 3: HLD Scoring and Documentation
The orthodontist calculates the HLD score and gathers all supporting documents. If the score meets or exceeds the Texas threshold for medical necessity, the orthodontist submits the case to the state’s review board.
Step 4: Prior Authorization Submission
All orthodontic treatments under Texas Medicaid require prior authorization from HHSC or the managed care organization handling the patient’s plan.
Step 5: Review and Decision
The case is reviewed by dental professionals contracted by Medicaid. If approved, the orthodontist can begin treatment. If denied, families may appeal the decision or explore payment options outside Medicaid.
What Orthodontic Services Texas Medicaid Covers
When approved, Texas Medicaid covers comprehensive orthodontic treatment and related services necessary to achieve proper alignment and bite correction.
Covered Services Include:
- Diagnostic records and orthodontic evaluation.
- Placement of braces (traditional metal braces).
- Adjustments and maintenance visits.
- Retainers after treatment completion.
- Emergency repairs related to Medicaid-approved orthodontic appliances.
Non-Covered or Limited Services:
- Cosmetic orthodontics (treatment for appearance only).
- Invisalign or clear aligners (unless deemed medically necessary, which is rare).
- Adult orthodontics not tied to medical procedures.
- Replacement of lost or broken retainers outside normal wear and tear.
In short, Medicaid in Texas focuses on functional corrections, not aesthetic improvements.
Orthodontic Providers Who Accept Texas Medicaid
Not all orthodontists in Texas accept Medicaid patients. Only providers who are registered and approved under the Texas Medicaid & Healthcare Partnership (TMHP) can offer covered orthodontic services.
Families can find participating orthodontists by:
- Visiting the TMHP Provider Lookup Portal.
- Calling their Medicaid managed care provider (such as DentaQuest, MCNA Dental, or UnitedHealthcare Dental).
- Asking their general dentist for referrals to Medicaid-accepting orthodontists in their area.
Texas Medicaid Managed Care Dental Plans
Children and teens under 21 enrolled in Texas Medicaid receive dental and orthodontic coverage through managed care organizations (MCOs). The three main providers currently serving Texas Medicaid dental patients are:
| Managed Care Provider | Coverage Type | Contact Information |
|---|---|---|
| DentaQuest | Medicaid and CHIP Dental | 1-800-516-0165 |
| MCNA Dental | Medicaid and CHIP Dental | 1-800-494-6262 |
| UnitedHealthcare Dental | Medicaid and CHIP Dental | 1-877-901-7321 |
These providers coordinate appointments, prior authorizations, and orthodontic claims under state and federal regulations.
Recent Updates to Medicaid Orthodontic Coverage in Texas (2026)
As of early 2026, the Texas Health and Human Services Commission (HHSC) continues to enforce the same strict criteria for orthodontic coverage.
Notable updates include:
- Digital Record Submissions: Orthodontists must now submit evaluations, photos, and HLD scores electronically through the TMHP portal for faster review.
- Improved Appeal Process: Families can appeal denied orthodontic claims through an online system that provides case tracking and faster response times.
- Enhanced Fraud Prevention: HHSC maintains oversight to prevent unnecessary orthodontic approvals—a safeguard introduced after prior overbilling scandals in the early 2010s.
These measures ensure that Medicaid-funded braces are reserved for children with legitimate medical needs.
Cost of Braces Without Medicaid Coverage
For families whose children do not qualify for Medicaid-covered braces, orthodontic treatment costs can vary widely depending on provider, location, and the type of braces.
| Type of Braces | Average Cost (Texas, 2026) |
|---|---|
| Traditional Metal Braces | $3,000 – $6,000 |
| Ceramic Braces | $4,000 – $7,500 |
| Invisalign (Clear Aligners) | $4,500 – $8,000 |
| Lingual (Behind-the-Teeth) Braces | $6,000 – $9,000 |
Some orthodontists offer payment plans or sliding-scale fees for families without coverage, and nonprofit dental clinics may provide discounted orthodontic services for children.
CHIP vs. Medicaid: What’s the Difference for Braces?
The Children’s Health Insurance Program (CHIP) covers Texas children in families who earn too much to qualify for Medicaid but still meet income requirements.
While CHIP provides preventive and restorative dental care, orthodontic coverage is also limited to medically necessary cases. Families with CHIP must go through the same evaluation and prior authorization process as Medicaid recipients.
The key difference is that CHIP families may have small copayments, depending on income level, while traditional Medicaid enrollees typically receive services at no out-of-pocket cost.
Tips for Parents Applying for Medicaid Braces in Texas
- Start Early: Begin the dental screening and referral process before age 15, as orthodontic evaluation is typically most effective during adolescence.
- Keep Detailed Records: Maintain dental records, X-rays, and correspondence related to your child’s case.
- Request a Second Opinion: If denied, ask another Medicaid-approved orthodontist for re-evaluation.
- Use the Appeal Option: Families have the right to appeal Medicaid denials within a specific timeframe, usually 90 days.
- Communicate With the MCO: Stay in contact with your managed care organization to track the application’s progress and understand any missing documentation.
Taking these steps can help families navigate the Medicaid approval process more effectively.
Key Takeaways for 2026
- Children under 21 may qualify for Medicaid-covered braces in Texas if the condition is medically necessary.
- Adults are not covered unless orthodontic treatment is part of a broader medical or surgical procedure.
- All cases require prior authorization and must meet the HLD score criteria.
- Coverage is administered through managed care dental providers like DentaQuest, MCNA, and UnitedHealthcare Dental.
- Families can appeal denials or seek alternative funding options if coverage is not approved.
If you’re a Texas parent wondering about Medicaid coverage for braces, the key is documentation and medical necessity. Have you gone through the Medicaid orthodontic approval process in Texas? Share your experience in the comments below!
