Pediatric dental is one of the essential health benefits on ACA-compliant plans. Does that mean that my insurance will cover braces for my son?

Q. I’ve read that pediatric dental is one of the essential health benefits on new plans.  Does that mean that my insurance will cover braces for my son?

A. Pediatric dental is one of the essential health benefits (EHB), meaning it has to be covered by health plans in the individual and small group markets. But it’s a bit more complicated than the other nine. Some medical policies have pediatric dental embedded in the plan, while plans in many states rely on separate stand-alone pediatric dental policies that supplement an enrollee's medical coverage.

But in general, most self-purchased plans will only cover orthodontia if it's deemed medically necessary. The determination of medical necessity is often left up to insurers,¹ and regulations vary from one state to another.

Non-medically necessary orthodontia (sometimes called “cosmetic orthodontia”) is generally not covered on individual market pediatric dental plans (it's not uncommon, however, for employer-sponsored plans to provide at least partial coverage for cosmetic orthodontia).² And the majority of orthodontic treatment — about 85% — is cosmetic rather than medically necessary.³

Within the pediatric dental EHB, states set guidelines in terms of the minimum benefits that insurers must provide. Most states require fairly comprehensive pediatric dental coverage, and most include at least some degree of coverage for medically necessary orthodontia (you can see each state's EHB benchmark plan details here). But again, most orthodontia treatment is cosmetic rather than medically necessary.

Utah opted to require its pediatric dental plans to cover only preventive care,⁴ as the EHB benchmark plan on which Utah's exchange plans are based does not cover restorative dental care⁵ (note that this is just the minimum requirement; pediatric dental plans in Utah have the option to provide more extensive coverage).

The American Dental Association noted in 2018 that Michigan's EHB benchmark plan also didn't include any coverage for medically necessary orthodontia,⁶ and that's still the case in 2026.⁷ Colorado's EHB benchmark plan does not include coverage of pediatric orthodontia,⁸ but Colorado statute requires health plans to cover medically necessary orthodontia when it's needed to treat a cleft lip or palate.⁹

HHS left it up to the states to define “medically necessary.” The American Association of Orthodontists has proposed criteria for determining whether orthodontic care is medically necessary,¹⁰ but there is no requirement that states adopt the same criteria. In some cases, orthodontics are covered if the child’s dental malocclusion is significant enough to cause problems with eating or speaking. In other cases, orthodontia is only covered if it is to treat congenital defects such as cleft palate or hemifacial microsomia, or following corrective jaw surgery (here's an example of the medical necessity requirements used by Aetna).

Check with your state division of insurance and the pediatric dental carriers in your state to see what’s required and what is offered as far as orthodontia coverage. And be sure to seek prior authorization if you are planning to use a pediatric dental plan to cover medically necessary orthodontia.

Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written hundreds of opinions and educational pieces about the Affordable Care Act for healthinsurance.org.