Does DentaQuest Cover Braces? Plans, Medicaid, and Prior Authorization

Whether DentaQuest covers braces depends entirely on which DentaQuest plan you have. Two of its individual personal dental plans cover orthodontics for both children and adults, but they’re sold in only one state. Marketplace plans cover braces only for children under 19, and only when medically necessary. Medicaid and CHIP plans cover braces only for children with a severe, medically necessary condition. Medicare Advantage plans administered by DentaQuest exclude orthodontics entirely.

Personal Dental Plans (Individual Coverage)

DentaQuest sells individual dental plans directly to consumers, and only two of them include orthodontic benefits: the Personal Dental Plan Comprehensive with Ortho 2000 and the Personal Dental Plan Comprehensive Plus with Ortho 1500. The Preventive, Basic, and Plus tiers do not cover braces at all.¹

These are the only DentaQuest plans that advertise orthodontic coverage for adults as well as children. Dependent children are covered up to age 26.²

The benefit structure on both plans is similar:

DentaQuest pays 50% of covered orthodontic charges.
A $1,500 lifetime orthodontic maximum per member applies, separate from the general annual dental maximum.
Orthodontia is covered once per lifetime.
A $50 per-person deductible ($150 per family) applies to orthodontic work.
There is a 12-month waiting period before orthodontic benefits begin.³²

Because braces typically cost several thousand dollars, the $1,500 lifetime cap means the member usually pays most of the bill. Members who use an out-of-network orthodontist can also be billed the difference between DentaQuest’s allowed charge and the provider’s actual fee.²

Where You Can Buy These Plans

Both orthodontic personal plans are currently sold only in Georgia. DentaQuest lists Pennsylvania, Tennessee, Texas, and Virginia as “coming soon,” but none had launched as of mid-2026.¹ If you live outside Georgia, these plans are not an option, and DentaQuest cautions that orthodontic coverage under these plans is available only “if it is offered in your state.”⁴

Marketplace (ACA) Dental Plans

On DentaQuest’s Affordable Care Act marketplace plans, orthodontic coverage is limited to children under age 19, and only when the treatment is medically necessary. Cosmetic braces are not covered. Adults age 19 and older get no orthodontic benefit on these plans.⁵⁶

For an eligible child, the plan pays 50% on the High tier or 40% on the Low tier. There is no separate orthodontic deductible. The calendar-year out-of-pocket maximum for pediatric dental is $350 per child, or $700 per family. DentaQuest pays the same percentage whether the provider is in-network or out, but out-of-network providers may balance-bill above the allowed amount.⁵

State-specific marketplace PPO plans follow the same pattern. In Texas, Georgia, and Louisiana, the PPO plans cover medically necessary orthodontics only for members under 19, with no waiting period for children. The High option pays 50%, Low and Basic options pay 40%, and adults are excluded.⁷⁸⁹

Medicaid and CHIP

DentaQuest administers Medicaid and CHIP dental benefits in a number of states, and these are the most restrictive plans of all for orthodontics. Braces are covered only for children (generally under age 21, with the cutoff varying by state) and only when a child has a severe malocclusion that affects dental health or function. Crooked teeth alone don’t qualify, and clear aligners such as Invisalign are treated as cosmetic upgrades and not covered.

Medical Necessity Must Be Documented

DentaQuest uses state-specific clinical scoring systems to decide whether a child’s case is severe enough to qualify. Colorado uses the Handicapping Labio-Lingual Deviation (HLD) Index, with automatic qualification for six serious conditions (such as congenital deformity or deep impinging overbite) or a minimum score on the HLD scoring sheet.¹⁰ Illinois uses the Salzmann Index with a minimum score requirement and limits orthodontic services to Medicaid participants under 21.¹¹ Texas Medicaid sorts cases into three severity levels, with the more severe levels requiring evidence of multiple qualifying conditions such as full cusp Class II or III malocclusion, overbite greater than 5mm, or overjet greater than 8mm.¹²

Every Medicaid orthodontic case requires prior authorization from DentaQuest before treatment can begin. The orthodontist submits radiographs, photographs or diagnostic models, and the scoring form.¹³

Who Is and Isn’t Covered

In Colorado, Health First Colorado covers orthodontics for children age 20 and younger. The Cover All Coloradans program, a separate Medicaid expansion category, does not cover orthodontics. Once Medicaid approves treatment, the payment is considered payment in full, and providers cannot bill the member for anything beyond the covered services.¹⁴¹³

In Georgia, orthodontics is excluded for adult Medicaid members and for pregnant women on Medicaid. PeachCare for Kids (Georgia’s CHIP) includes what DentaQuest describes as “a very small orthodontic benefit” for children who meet medical necessity criteria. Members are directed to contact Amerigroup Member Services at 1-800-600-4441 for specific amounts.¹⁵

Texas CHIP is especially narrow. Under CHIP, orthodontics is treated as a medical benefit rather than a dental one, and coverage is limited to pre- or post-surgical orthodontic treatment for craniofacial anomalies such as cleft lip or palate, severe traumatic skeletal deviations, or severe facial asymmetry from a congenital syndrome or tumor treatment. Routine malocclusion is not covered under Texas CHIP.¹⁶

Medicare Advantage

If your dental benefit comes through a Medicare Advantage plan administered by DentaQuest, braces are not covered. The 2026 SCAN Dental Guide, one example of a Medicare Advantage plan DentaQuest administers, lists orthodontic treatment as an exclusion, and no orthodontic procedure codes appear on its schedule of covered benefits.¹⁷

If DentaQuest Denies Prior Authorization

When DentaQuest denies prior authorization for braces, you can appeal. The process depends on the plan and the state.

For Texas Medicaid, you must file a written appeal within 60 calendar days of the denial. DentaQuest responds within 30 calendar days. If the appeal is denied, you can request a State Fair Hearing within 120 days, or ask for a free External Medical Review by an independent organization before the hearing. Emergency appeals are available when a child’s health is at immediate risk, with decisions in three business days.¹⁸

In Colorado, members can request reconsideration within 60 days by phone, fax, or mail, and DentaQuest responds within 10 business days. A State Fair Hearing before an Administrative Law Judge can be requested within 60 days after that. For children age 20 and younger, requests are also reviewed under the EPSDT medical necessity rules, which add protection for pediatric services.¹⁹

Finding an In-Network Orthodontist

DentaQuest’s “Find a Dentist” tool lets you filter by ZIP code, plan name, and provider specialty, including an Orthodontist option.²⁰ Some plans pay the same coinsurance percentage whether the orthodontist is in-network or not, but an out-of-network provider can bill you the difference between DentaQuest’s allowed amount and the actual charge, which can add significantly to what you pay. Confirming the orthodontist is in-network before treatment begins is the simplest way to avoid that surprise.²

1
DentaQuest. Personal Dental Plans
2
DentaQuest. Comprehensive Plus With Ortho 1500 Benefit Summary
3
DentaQuest. Comprehensive With Ortho 2000 Benefit Summary
4
DentaQuest. Personal Plans Member FAQs
5
DentaQuest. Marketplace Benefit Summary – Individual/Family High
6
DentaQuest. Marketplace Benefit Summary – Individual/Family Low
7
DentaQuest. Texas PPO Benefit Summary
8
DentaQuest. Georgia PPO Benefit Summary
9
DentaQuest. Louisiana PPO Benefit Summary
10
DentaQuest. Colorado HLD Index Score Sheet
11
Illinois Department of Human Services. Illinois Medicaid Orthodontic Coverage Policy
12
Texas Medicaid & Healthcare Partnership. Changes to Texas Health Steps Orthodontic Dental Services Benefit
13
DentaQuest. Colorado Criteria for Orthodontics
14
DentaQuest. Health First Colorado Dental Coverage
15
DentaQuest. Georgia Medicaid Dental Coverage – Amerigroup
16
InsureKidsNow.gov. Dental Benefits – Texas CHIP
17
SCAN Health Plan. 2026 SCAN Dental Guide – Allowance
18
DentaQuest. Texas Medicaid Complaints and Appeals
19
DentaQuest. Colorado Appeals and Grievances
20
DentaQuest. Find a Dentist