CMS capped Medicare Advantage ortho benefits. Your 65-year-old isn't getting braces.

CMS capped Medicare Advantage ortho benefits. Your 65-year-old isn't getting braces.

CMS finalized the 2026 Medicare Advantage ortho cap: $1,200 annual maximum on all orthodontic services. That's roughly one-third of a full adult case. Even the simplest case costs more.

Translation: no adult Medicare Advantage patient is getting full orthodontic treatment under these plans. You might do limited tooth movement or retention cases, but the economics don't work for a comprehensive case. The cap is a compliance floor, not a clinical reality.

UnitedHealthcare went further. Effective Jan 1, they dropped periodontal maintenance coverage on their preventive-only plans. That's a different problem, but it signals the same strategy: shrink the benefit, shift the burden to the patient or the provider.

This isn't a surprise. Medicare Advantage plans are under margin pressure from CMS, and they're cutting non-core benefits first. Ortho was always optional. Perio maintenance is now optional too.

Smart practices responded by building a private ortho case load already. DSOs that relied on Medicare to fill their ortho schedule are scrambling. Independent practices adapted. It's 2026—adapt or your chair time fills with someone else's patient.

The message from payers is clear: don't count on government plans for elective procedures. Build your FFS and private case load like your life depends on it.