It seems that everywhere you look, people are improving their smiles with orthodontic treatment. The American Association of Orthodontics reports that just under 4 million pediatric patients and millions of adults are currently undergoing treatment, and it’s clear why.
After undergoing orthodontic treatment like Invisalign or conventional fixed braces, patients often report:
- Higher confidence and self-esteem
- Better oral health
- Improved appearance
With all the health and cosmetic benefits orthodontic treatment can offer, it’s no surprise that more people than ever are exploring their options. Still, one of the biggest barriers for many is uncertainty around insurance coverage. A question we hear often is whether orthodontic treatment, especially Invisalign, is covered under California’s Medical Assistance Program, better known as Medi-Cal.
Medi-Cal was designed to provide comprehensive coverage to low-income Californians and currently covers more than 13 million people. As a comprehensive healthcare program, Medi-Cal covers many healthcare necessities like personal care physician appointments, dental work, and hospitalizations. But what about orthodontics and Invisalign?
As with other insurance providers, Medi-Cal users don’t always know exactly what is and isn’t covered by their plan. In the orthodontist’s office, this leads to questions including:
- Does Medi-Cal cover orthodontics?
- Does Medi-Cal cover Invisalign?
- Which orthodontic problems are covered by Medi-Cal?
- Who is eligible to receive orthodontic care through Medi-Cal?
We’ll help you find those answers.
What Does Medi-Cal Cover?
Medi-Cal was started in 1965 through the Department of Public Social Services and has provided Californians with a wide variety of healthcare. Medi-Cal’s benefits cover the following treatments:
|
What Does Medi-Cal Cover? |
||
|
Personal care physician visits |
Hospitalizations |
Pregnancy care |
|
Dental appointments |
Preventative care |
Prescription medicines |
So, does Medi-Cal cover Invisalign? In short, it depends. While Medi-Cal has included orthodontic benefits since 1991, coverage is limited and based on specific criteria. Eligibility depends on both the patient’s age and the misalignment severity. Only cases that meet certain medical necessity standards may qualify for treatment under the program, and even then, traditional braces are far more likely to be approved than Invisalign.
Does Medi-Cal Cover Invisalign?
For several reasons, Invisalign is typically a bit more expensive than traditional metal braces. Regardless, if your Medi-Cal coverage would pay for braces, it usually will pay for part of your Invisalign treatment instead.
Talk with your orthodontist and see if Invisalign aligners would be a good option for your orthodontic needs. Options vary based on plan, but a Medi-Cal plan typically covers Invisalign if you meet certain specific (but common) conditions.
Medi-Cal covers orthodontics if:
|
When Does Medi-Cal Cover Orthodontics? |
|
|
They are medically necessary |
Medically necessary orthodontic conditions include:
|
|
You get prior authorization |
|
|
You meet the age requirements |
|
|
Your orthodontist is in-network |
In order to use your Medi-Cal orthodontic benefits, you must receive orthodontic treatment from:
|
|
You’re prepared for out-of-pocket costs |
While Medi-Cal covers the majority of orthodontic costs for eligible recipients, some out-of-pocket costs, such as copayments or deductibles, may apply depending on the individual’s coverage |
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!
What are the Limits of Medi-Cal Coverage for Invisalign?
While Medi-Cal does cover orthodontic work, the program does not cover all treatments. Specifically, age restrictions make many Medi-Cal patients ineligible for orthodontic coverage.
While we at BHO think there’s never a bad time to get orthodontic care and improve your smile, since 2022, Medi-Cal for Invisalign has only been available to patients under the age of 21—no orthodontic coverage extensions are allowed.
For individuals under 21, Medi-Cal coverage is still only available for issues considered to be “medically necessary” as defined by Title 22 of the California Code of Regulations. To paraphrase Title 22 §51340.1, Medi-Cal covers treatments that will:
- Relieve pain
- Prevent infection
- Restore teeth
- Aid in maintaining dental health
- Correct physical defects
In accordance with these terms, six conditions will automatically qualify for coverage under Medi-Cal. These conditions include:
|
What Orthodontic Treatments Are Always Covered by Medi-Cal? |
|
 |
Cleft palate malformations |
 |
Craniofacial irregularities |
 |
Deep overbites causing the lower incisor teeth to damage the soft palate tissues |
 |
Crossbites where anterior teeth harm soft tissues |
 |
Severe overjets measuring over 9 mm |
 |
Severe trauma (e.g., bone/tissue loss caused by burns, accidents, etc.) |
If you or your child has these conditions and you are covered by Medi-Cal, schedule an appointment with our office and inquire about treatment.
Beverly Hills Orthodontics Is Your Office for Medi-Cal-covered Invisalign
If you need orthodontics, “Does Medi-Cal cover Invisalign?” is likely just the first question. At Beverly Hills Orthodontics, we are here to answer any questions and provide top-tier care for all our current and future patients.
As a Blue Diamond Top 1% Invisalign practice, Beverly Hills Orthodontics is recognized as one of the top Invisalign providers in the country. Our founder, Dr. Monica Madan, uses both Invisalign and conventional braces to treat Medi-Cal-covered issues and create healthy, beautiful smiles. Call today to learn more!
Have more questions like “Does Medi-Cal cover Invisalign?” Call or text us at (310) 785-0770. Or visit our contact page to book a consultation.