As an approved Medicaid Orthodontist we get constantly get asked about Medicaid (Public Aid) orthodontic coverage for braces in the state of Wisconsin. We have a lot of experience when it comes to working with Medicaid in Colorado and can answer all you questions on the topic.
Who can get braces through Medicaid (Public Aid, Health First Wisconsin State Insurance) in the state of Wisconsin?
In Wisconsin, Medicaid only covers orthodontic treatment (braces) for children under the age 21. So if you are an adult on Medicaid and want orthodontic treatment such as braces Medicaid insurance will not help with the costs and you’ll need to pay for it out of pocket.
For children under 21, however, Medicaid will pay for the costs of braces in full, if they determine that the need for braces is medically necessary.
What is medical necessity for braces?
In order for orthodontic treatment to be considered medically necessary, the case should include the treatment of craniofacial abnormalities, or severe bite problems. Also, treatment may be covered when provided in conjunction with other medical issue(s), such as a syndrome, trauma, etc. For example, a severe handicapping bite which impairs a patient’s physical or emotional health may require medically necessary orthodontic treatment.
In the state of Wisconsin, you can have your child evaluated for orthodontic treatment once per year. So if they get denied for braces in one year, you can try again the next year. Typically Medicaid will allow up to three approval attempts. If your child gets denied for treatment before he/she has all adult teeth, it may be a good idea to wait a year and try again.
What is the process of Medicaid pre-approval for braces in Wisconsin?
To start orthodontic pre-approval process, you need to schedule a consultation at our office first. At the consultation appointment, we will obtain photos and X-rays required by Medicaid for pre-approval. One of our orthodontists will also make an evaluation along with filling out all necessary forms and reports needed for Medicaid office to review your case. We send this in to Medicaid administrators. They evaluate the case and will typically provide their determination within four to six weeks. They will notify both our office and your family about their decision, by mail. If your child gets denied, and we noted in our report that the case was extremely severe, we may choose to appeal. If the appeal is denied, your family has the further right to appeal. If approved, you would call our offices and make an appointment. As long as you have Medicaid coverage on the day of the appointment, Medicaid will then cover the cost of treatment in full.
Call our Wisconsin office today and schedule your consultation for orthodontic pre-approval by Medicaid (Public Aid).
To find an orthodontist in Wisconsin that accepts Health First Wisconsin Insurance (Medicaid) visit Medicaid Orthodontist Wisconsin.