Does Amerigroup Cover The Cost Of Braces?
Navigating dental insurance can be confusing, especially when it comes to orthodontic treatment like braces. If you are an Amerigroup member or considering enrolling, you may wonder whether your plan covers the cost of braces.
Amerigroup is a managed care company that provides health insurance, including dental coverage, primarily through government-sponsored programs like Medicaid and Medicare Advantage. The answer to whether braces are covered depends on your specific plan, your age, and the medical necessity of the treatment. This guide breaks down everything you need to know about Amerigroup and orthodontic coverage.
Understanding Amerigroup
Amerigroup is a subsidiary of Elevance Health (formerly Anthem). It focuses on serving low-income families, children, pregnant women, and individuals with disabilities through publicly funded programs.
Key Programs:
- Medicaid: State-administered health insurance for low-income individuals.
- CHIP (Children’s Health Insurance Program): Coverage for children in families that earn too much for Medicaid but cannot afford private insurance.
- Medicare Advantage: Private plans that provide Medicare benefits.
Dental coverage through Amerigroup varies significantly depending on which program you are enrolled in and which state you live in.
Braces Coverage for Children (Medicaid/CHIP)
This is the most important area to understand. For children, orthodontic coverage is often available but strictly regulated.
The EPSDT Mandate
Under federal law, Medicaid programs must provide comprehensive dental care to children through the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit. This includes medically necessary orthodontics.
What Does “Medically Necessary” Mean?
Braces are not considered medically necessary if the sole purpose is cosmetic improvement. They are considered medically necessary when there is a functional problem that affects the child’s health.
Conditions That May Qualify for Braces:
- Severe Malocclusion: A significant misalignment of the teeth or jaw.
- Cleft Palate or Craniofacial Anomalies: Birth defects affecting the mouth and face.
- Traumatic Injury: Damage to the teeth or jaw from an accident.
- Severe Overbite or Underbite: When the bite causes difficulty eating, speaking, or breathing.
- Impacted Teeth: Teeth that are stuck and cannot erupt properly.
The Scoring System
Many state Medicaid programs use a standardized scoring system to determine eligibility. Common systems include:
- Handicapping Labio-Lingual Deviation (HLD) Index: Measures the severity of misalignment. A score above a certain threshold (often 26) is required for coverage.
- Salzmann Index: Another scoring tool used to assess malocclusion severity.
If your child’s condition scores below the threshold, braces will be considered cosmetic and will not be covered.
State-by-State Variation
Medicaid is administered by states, so coverage varies.
| State | Amerigroup Braces Coverage (Children) |
|---|---|
| Texas | Covered if HLD score is 26 or higher |
| Florida | Covered if medically necessary with prior authorization |
| Georgia | Limited coverage, strict HLD requirements |
| California | Covered for qualifying conditions |
| New York | Comprehensive orthodontic coverage for qualifying children |
Always check with your specific Amerigroup plan in your state.
Braces Coverage for Adults (Medicaid)
This is where coverage becomes very limited.
General Rule:
Most state Medicaid programs do not cover orthodontic treatment for adults. Braces are considered a cosmetic procedure for adults unless there is a severe medical necessity (like reconstructive surgery after an accident).
Exceptions:
- Trauma: If you are in an accident and your teeth are damaged, orthodontics may be covered as part of the reconstructive treatment.
- Surgical Cases: If you require jaw surgery, braces may be covered as part of the surgical plan.
- Cleft Palate: Adults with congenital conditions may qualify.
These exceptions are rare and require extensive documentation and prior authorization.
Braces Coverage for Medicare Advantage Members
Amerigroup also offers Medicare Advantage plans. Original Medicare does not cover dental care, including braces. However, some Medicare Advantage plans include dental benefits.
What to Know:
- Routine Dental: Many Amerigroup Medicare Advantage plans include coverage for cleanings, exams, and fillings.
- Orthodontics: Braces for adults are almost never covered. If they are, it is usually limited to a small allowance (e.g., $500 – $1,000) and only for specific medical conditions.
How to Check Your Coverage
If you are an Amerigroup member and want to know if braces are covered, follow these steps.
Step 1: Review Your Member Handbook
Your plan documents will outline dental benefits, including any orthodontic coverage. Look for terms like “orthodontics,” “braces,” or “malocclusion treatment.”
Step 2: Call Member Services
The phone number on the back of your insurance card connects you to Amerigroup Member Services. Ask specifically:
- “Does my plan cover orthodontic treatment for my child/adult?”
- “What are the medical necessity criteria?”
- “Do I need a referral from a general dentist?”
Step 3: Get a Referral
If coverage is possible, your child’s general dentist must refer them to an orthodontist for an evaluation. The orthodontist will document the case and submit a prior authorization request.
Step 4: Prior Authorization
Amerigroup (or the state Medicaid agency) will review the request. They will assess the severity of the case using the HLD or similar index. If approved, treatment can begin.
What If Braces Are Not Covered?
If your Amerigroup plan denies coverage for braces, you have options.
1. Appeal the Decision
You have the right to appeal a denial. Provide additional documentation from your orthodontist explaining why the braces are medically necessary.
2. Seek a Second Opinion
Another orthodontist may provide a different assessment that strengthens your case.
3. Payment Plans
Many orthodontists offer interest-free payment plans. A typical plan involves a down payment and monthly installments.
4. Dental Schools
Dental schools offer orthodontic treatment at reduced rates (often 30-50% off). Students perform the work under supervision.
5. Charitable Programs
Organizations like Smiles Change Lives provide low-cost orthodontic care for qualifying families.
The Cost of Braces Without Insurance
If you must pay out of pocket, here is what to expect.
| Type of Braces | Average Cost (USD) |
|---|---|
| Metal Braces | $3,000 – $7,000 |
| Ceramic Braces | $4,000 – $8,000 |
| Lingual Braces | $8,000 – $13,000 |
| Invisalign | $4,000 – $8,000 |
Amerigroup vs. Other Medicaid Plans
Amerigroup is one of several managed care organizations that administer Medicaid benefits. Coverage for braces is generally similar across these plans because it is dictated by state Medicaid policy, not the specific insurer.
Competitors:
- UnitedHealthcare Community Plan
- Molina Healthcare
- Centene (WellCare)
If you have a choice of plan, the coverage for braces will likely be the same. The difference will be in the network of orthodontists available.
Important Notes for Parents
If your child has crooked teeth, do not assume braces are purely cosmetic. Crooked teeth can lead to:
- Difficulty Chewing: Affecting nutrition.
- Speech Problems: Misaligned teeth can cause lisps or other speech issues.
- Increased Risk of Decay: Crowded teeth are harder to clean.
- Jaw Pain: Misaligned bites can cause TMJ disorders.
These functional problems are what Medicaid programs look for when determining “medical necessity.”
“Many parents give up when they hear ‘cosmetic,’ but a proper evaluation is essential. A severe overbite is not cosmetic; it is a health problem. Document the functional issues and advocate for your child.” — A Pediatric Dentist in Houston
Conclusion
Amerigroup covers the cost of braces primarily for children enrolled in Medicaid or CHIP when the treatment is deemed medically necessary. Adults rarely qualify unless there is severe trauma or surgical need. Coverage varies by state and requires prior authorization based on standardized severity scoring. If coverage is denied, payment plans and dental schools offer alternative paths to affordable orthodontic care.
Additional Resource
To understand your state’s specific Medicaid dental policies and the criteria for orthodontic coverage, visit your state’s Medicaid website or the Medicaid.gov portal for links to state resources.
Frequently Asked Questions (FAQ)
Q: Does Amerigroup cover Invisalign for kids?
A: Usually not. Medicaid programs typically cover traditional metal braces only, as they are the most cost-effective. Invisalign is considered a cosmetic alternative and is rarely approved.
Q: How do I know if my child qualifies for braces through Amerigroup?
A: Your child needs an evaluation by an orthodontist. They will assess the severity of the misalignment and submit documentation. The state uses a scoring system (like HLD) to determine eligibility.
Q: Can adults get braces through Amerigroup?
A: Very rarely. Adult orthodontics is only covered in severe cases involving trauma, surgery, or congenital defects. Cosmetic braces are not covered.
Q: What is the HLD score required for braces?
A: In most states using the HLD index, a score of 26 or higher is required for Medicaid coverage. Conditions like severe overjet, deep bite, or impacted teeth contribute points.
Q: How long does the approval process take?
A: After the orthodontist submits the prior authorization request, it can take 2 to 6 weeks for a decision, depending on the state and plan.
