Does Medicaid Cover Braces in Texas: 2026 Full Guide on Eligibility, Rules, and Coverage

Does Medicaid cover braces in Texas in 2026? The answer depends entirely on age, medical necessity, and state-specific rules under the Texas Health and Human Services Commission (HHSC). As of January 2026, Medicaid in Texas does cover braces for children and teenagers under 21 who meet strict medical necessity standards under the Texas Health Steps (THSteps) dental program. However, adults do not qualify for Medicaid-funded orthodontic treatment except in rare cases tied to severe medical or surgical needs.

This comprehensive guide explains how Medicaid coverage for braces works in Texas, who qualifies, what documentation is required, and what recent updates have been implemented to make the process more efficient.

How Texas Medicaid Works for Dental and Orthodontic Care

Texas Medicaid provides medical and dental coverage to low-income residents through a combination of federal and state funding. Dental benefits for children and teens fall under the Texas Health Steps (THSteps) program, also called the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit.

THSteps ensures that young patients receive preventive and medically necessary dental treatments — including orthodontics when a child’s condition affects their health, speech, or ability to chew properly. However, orthodontic treatment such as braces is not automatically approved and must undergo a prior authorization review process.

Who Qualifies for Medicaid-Covered Braces in Texas (2026)

Eligibility for Medicaid-covered braces depends primarily on the patient’s age and the severity of the dental condition.

Eligibility Criteria

To qualify, the patient must:

• Be enrolled in Texas Medicaid or CHIP (Children’s Health Insurance Program).
• Receive a referral from a Medicaid-approved dentist or orthodontist.
• Undergo a comprehensive orthodontic evaluation proving medical necessity.

What “Medically Necessary” Means for Medicaid Braces

The term “medically necessary” is the key factor in determining Medicaid eligibility for braces. Medicaid in Texas only covers orthodontic treatment when the dental condition directly impacts physical health or daily function.

Conditions That May Qualify as Medically Necessary

• Severe overbite or underbite that interferes with eating or speaking.
• Crossbite causing abnormal jaw alignment or pain.
• Cleft palate, craniofacial anomaly, or congenital defect affecting oral structure.
• Deep bite or open bite leading to tooth damage or gum issues.
• Extreme tooth crowding causing hygiene or speech difficulties.
• Facial trauma requiring orthodontic correction.

Cosmetic concerns, such as slightly crooked teeth or mild spacing, do not qualify for Medicaid coverage.

The HLD Index and Orthodontic Scoring

Texas Medicaid uses the Handicapping Labio-Lingual Deviation (HLD) Index to measure the severity of orthodontic problems. This system assigns points based on factors such as bite alignment, spacing, and jaw irregularities.

• A score of 26 points or higher typically qualifies for Medicaid-covered braces.
• Lower scores usually indicate cosmetic rather than medical need.

The orthodontist documents this score as part of the prior authorization package submitted to the Texas Health and Human Services Commission.

How to Apply for Medicaid-Covered Braces in Texas

Applying for orthodontic coverage under Texas Medicaid involves several verification steps. Approval is not automatic and may take several weeks.

Step 1: Obtain a Dental Referral

The process begins with a referral from a primary dentist, pediatric dentist, or family physician who identifies potential orthodontic concerns.

Step 2: Visit a Medicaid-Approved Orthodontist

Only orthodontists registered under the Texas Medicaid & Healthcare Partnership (TMHP) can provide approved evaluations and treatment.

Step 3: Orthodontic Evaluation and Documentation

The orthodontist conducts a full assessment, including:

• Panoramic X-rays and dental impressions.
• Photographs of facial and dental structure.
• HLD scoring to determine medical necessity.

Step 4: Submit Prior Authorization Request

All orthodontic claims must go through the prior authorization process with HHSC or the family’s Medicaid managed care dental plan. Supporting documentation must demonstrate that braces are essential for physical health, not cosmetic improvement.

Step 5: Await Review and Approval

Medicaid dental administrators, such as MCNA Dental or DentaQuest, review the submission. Approval or denial is typically issued within 30 to 45 days. Families can appeal denials by providing additional evidence.

Orthodontic Services Covered by Texas Medicaid

Once approved, Medicaid covers all orthodontic services required to complete medically necessary treatment.

Covered Orthodontic Services Include:

• Diagnostic exams and orthodontic records.
• Placement of traditional metal braces.
• Routine adjustment appointments.
• Retainers after treatment.
• Repairs of damaged orthodontic appliances caused by normal wear.

Services Not Covered Under Texas Medicaid:

• Clear braces or Invisalign aligners (unless specifically approved for medical reasons).
• Adult orthodontics for cosmetic purposes.
• Replacement retainers for loss or neglect.
• Teeth whitening or cosmetic dental procedures.

Medicaid’s goal is to ensure function and health—not aesthetics.

Which Dental Plans Handle Medicaid Orthodontic Coverage in Texas

Texas Medicaid uses managed care organizations (MCOs) to administer dental and orthodontic services. Families can choose or are automatically assigned to one of the state’s three dental plan providers.

These providers manage prior authorizations, referrals, and orthodontic claims for Medicaid enrollees across Texas.

Texas Medicaid Orthodontic Coverage for Adults

Adult orthodontic coverage under Texas Medicaid is extremely limited. Medicaid only approves braces for adults when orthodontic treatment is part of a medically necessary surgical or reconstructive procedure.

Adult Coverage Scenarios May Include:

• Jaw realignment surgery after trauma or accident.
• Orthodontic correction required before oral surgery.
• Severe facial deformities causing breathing or eating impairment.

Outside of these cases, adults must seek private orthodontic financing or use dental discount programs.

Texas CHIP and Braces Coverage

The Children’s Health Insurance Program (CHIP) serves families whose income exceeds Medicaid limits but remains below private insurance affordability. Like Medicaid, CHIP covers orthodontic treatment only when medically necessary.

CHIP families may face small copayments or annual deductibles, but the approval criteria mirror those used by Medicaid, including the same HLD scoring and prior authorization steps.

Recent 2026 Updates to Medicaid Orthodontic Policies in Texas

The Texas Health and Human Services Commission (HHSC) and the Texas Medicaid & Healthcare Partnership (TMHP) have made several recent updates to improve transparency and efficiency in orthodontic claims:

• Digital Case Submission: All orthodontic prior authorizations must be submitted electronically through the TMHP provider portal.
• Updated HLD Evaluation Form: The latest HLD form requires additional details on functional impairments and long-term oral health impacts.
• Enhanced Fraud Monitoring: Following previous overbilling issues, Medicaid now uses data analytics to detect false orthodontic claims.
• Faster Appeal Processing: Families can appeal denied orthodontic claims online and track their status in real time.

These improvements aim to streamline the approval process while preventing unnecessary or fraudulent claims.

Cost of Braces Without Medicaid Coverage

For patients who do not qualify for Medicaid or CHIP coverage, the cost of braces can vary significantly depending on the treatment type and provider.

Some orthodontists offer payment plans, sliding-scale pricing, or nonprofit dental clinic options for low-income families.

How to Find an Orthodontist Who Accepts Texas Medicaid

Families seeking braces under Medicaid must visit an orthodontist who is officially enrolled with the Texas Medicaid & Healthcare Partnership.

You can locate providers by:

• Visiting the TMHP Provider Search Tool online.
• Contacting your managed care dental provider (DentaQuest, MCNA, or UnitedHealthcare).
• Asking your general dentist for a Medicaid-participating orthodontist referral.

Always confirm participation before scheduling a consultation to avoid unexpected costs.

Tips for Getting Medicaid Braces Approved in Texas

Because orthodontic approval is not automatic, preparation and documentation are key.

1. Start Early: Children aged 10–14 typically have the best chance of approval, as orthodontic issues are easier to document before permanent teeth fully develop.
2. Get a Complete Evaluation: Choose an orthodontist who has experience submitting Medicaid cases and understands the HLD scoring process.
3. Gather Documentation: Keep records of speech difficulties, chewing issues, or other medical problems linked to dental misalignment.
4. Follow Up Regularly: Contact your dental plan provider to track the authorization progress.
5. Appeal If Denied: Families can appeal denied claims by submitting updated documentation or seeking a second professional evaluation.

Following these steps can significantly increase the chances of approval.

Other Dental Services Covered by Texas Medicaid for Children

Texas Medicaid provides comprehensive dental care for children and teens under 21 through THSteps.

Covered Dental Services Include:

• Routine checkups and cleanings.
• X-rays and fluoride treatments.
• Fillings, crowns, and extractions.
• Space maintainers and sealants.
• Medically necessary orthodontic care.

This broad coverage ensures that children receive preventive and restorative dental services to promote lifelong oral health.

Key Takeaways for Families in 2026

• Medicaid in Texas covers braces for children and teens under 21 if treatment is medically necessary.
• Adults rarely qualify unless orthodontics is part of a surgical or reconstructive medical procedure.
• Medicaid requires prior authorization and a qualifying HLD score of 26 or higher.
• Approved orthodontic services include exams, braces, adjustments, and retainers.
• Applications are managed through dental care organizations such as DentaQuest, MCNA Dental, and UnitedHealthcare Dental.
• Denied claims can be appealed, and families can track the process online.

If you’re a parent wondering whether your child qualifies for Medicaid-covered braces in Texas, focus on medical necessity and documentation. Have you applied for orthodontic approval through Texas Medicaid? Share your experience and insights below!