Do ACA child dental plans cover braces, and who are they best for?

Short answer: ACA (Marketplace) dental plans for children only pay for braces when they are medically necessary. Braces for crooked or crowded teeth are usually treated as cosmetic and are not covered. If your child needs braces for a common reason, a private dental plan with orthodontic coverage is usually the better fit.

Does ACA child dental cover braces?

Dental care for children under 19 is an essential health benefit under the Affordable Care Act, and orthodontia is part of that benefit. The catch is that it is limited to medically necessary orthodontia. Every 2027 Marketplace child dental plan we reviewed lists it that way, and most pay about 50% of the cost after the deductible once the treatment is approved.

What counts as "medically necessary"?

Each plan sets its own rules, but it usually means a severe problem that affects how a child eats, speaks or breathes, such as:

• Cleft lip or cleft palate
• A severe overbite, underbite or crossbite
• Teeth that are badly out of position or impacted, or that cause damage to the gums or other teeth
• Jaw problems that make chewing or speaking difficult

Plans often use a scoring test of the bite (many use the HLD index) and require approval before treatment starts. Your orthodontist can usually tell you after an exam whether your child is likely to qualify.

What is usually not covered?

Braces to straighten crooked or crowded teeth, close gaps or improve appearance are considered cosmetic. That is the reason most kids get braces, so most families should not count on an ACA dental plan to pay for them.

Who are ACA child dental plans best for?

• Kids who will likely qualify for medically necessary braces. If the orthodontist expects approval, an ACA plan can pay more than a private plan with a $1,000 to $1,500 lifetime orthodontic maximum.
• Kids who need a lot of dental work. Children's benefits on these plans have no yearly dollar maximum, and your out-of-pocket costs are capped each year. On the 2027 plans we reviewed, the cap was $450 for one child or $900 for two or more.
• Families already enrolling in a Marketplace health plan. You can only buy a Marketplace dental plan at the same time you enroll in a Marketplace health plan.
• Families whose child's dentist and orthodontist are in the plan's network. Networks vary a lot by plan, so check both offices before you choose.

Who should look at a private dental plan instead?

• Your child needs braces for crooked or crowded teeth.
• Your child's dentist or orthodontist is not in any Marketplace dental network.
• You do not have a Marketplace health plan (for example, you have job-based or off-exchange coverage).
• Your Marketplace health plan already includes children's dental coverage, so a second plan would double up.

Private plans that include orthodontia for children usually have a waiting period of about 12 months before braces are covered, then pay around 50% up to a lifetime maximum. If braces are a year or more away, starting a private plan now can line up the waiting period with the treatment.

Tips before you choose

1. Ask your orthodontist whether your child's case would be considered medically necessary.
2. Check that your child's dentist and orthodontist are in network on the exact plan.
3. Look at the waiting period, coinsurance and lifetime orthodontic maximum.
4. Check whether your health plan already includes children's dental.

Talk to a licensed iHealthAgents advisor

We can compare Marketplace and private dental plans side by side and check your child's dentist and orthodontist for you, at no cost. Get a dental quote or call Illinois 312-726-6565 or Texas 972-666-0578.

This article is for educational purposes. Benefits, networks, waiting periods and out-of-pocket limits vary by plan and state; the figures above are from 2027 Marketplace plans we reviewed and are not a guarantee of coverage. Always check the plan's brochure before you enroll.