Medicaid is a joint federal and state program providing health coverage to low-income adults, children, pregnant women, elderly adults, and people with disabilities. Families often ask if this coverage extends to orthodontic treatment, such as braces. In Indiana, coverage is highly restricted and only applies when the need for braces is directly related to a severe, functionally debilitating condition. This limitation ensures resources focus on treatments that improve health function rather than those that are purely cosmetic.
Indiana Medicaid Programs and Orthodontic Coverage
Orthodontic services in Indiana are covered under the state’s primary Medicaid programs for children, including Hoosier Healthwise and Hoosier Care Connect. These programs are administered by the Indiana Family and Social Services Administration (FSSA), which oversees the Indiana Health Coverage Programs (IHCP). Coverage is limited to members aged 20 or younger, requiring that treatment be deemed medically necessary.
The Healthy Indiana Plan (HIP) may also provide coverage for dependents, but the medical necessity requirement applies across all programs. Coverage is intended for those whose dental alignment issues present a significant health or functional impairment, not for every child needing straight teeth.
The Criteria for Medical Necessity
Indiana Medicaid strictly limits orthodontic coverage to cases involving severe malocclusion—a misalignment of the teeth or jaws causing a functional problem. Coverage is approved only for members with congenital or acquired craniofacial deformities, such as cleft palate, or those with extremely severe bite problems. Determination is based on specific, objective clinical measurements, not subjective appearance. The IHCP criteria align with standards for determining severe functional impairment.
Required measurements for coverage may include an overjet, where the upper teeth protrude past the lower teeth, that is equal to or greater than nine millimeters. A reverse overjet, or underbite, of three and a half millimeters or more is also considered a sign of medical necessity.
Other structural issues meeting the threshold include a lateral or anterior open bite measuring four millimeters or greater. This measurement signifies a large vertical gap between the upper and lower teeth when the jaw is closed, which can severely impede chewing or speech. Providers must also document a posterior crossbite that prevents functional occlusal contact, meaning the teeth cannot meet properly to chew. These objective measurements ensure that only the most functionally impairing cases are considered for state-funded treatment.
Navigating the Prior Authorization Process
Before treatment begins, the orthodontist must complete a mandatory Prior Authorization (PA) process with the state’s utilization management entity. The PA request is the official submission seeking approval and payment from Indiana Medicaid. This step is required for all orthodontic services.
The orthodontist must submit comprehensive documentation proving the medical necessity of the proposed treatment. This packet includes recent full-mouth X-rays, detailed dental models of the patient’s teeth and bite, and clinical photographs. The submission must also include a thorough, step-by-step treatment plan outlining the phases and expected length of correction.
The state reviews the documentation to confirm the patient’s condition meets the specific clinical severity criteria for coverage. If the request is denied, the provider and patient can pursue an appeal, often involving an Administrative Review or a peer-to-peer discussion. This process can take several weeks or months, and no services should be rendered until official authorization is received.
Practical Limitations and Provider Selection
The coverage provided by Indiana Medicaid focuses solely on correcting medically necessary conditions and does not extend to purely aesthetic treatments. Orthodontic treatment sought for cosmetic reasons will not be covered under the program. Furthermore, certain related items and services, such as replacing lost or broken retainers, are generally considered the financial responsibility of the patient.
A practical challenge for recipients is finding a qualified orthodontist who is an enrolled Indiana Health Coverage Programs provider and actively accepting new Medicaid patients. Not all orthodontic practices choose to participate in the state’s program. Members should use the Indiana Health Coverage Programs Provider Locator tool or contact their specific Managed Care Entity to find a list of participating orthodontists. It is necessary to confirm directly with the office that they are accepting new patients under the patient’s specific Medicaid plan before scheduling a consultation.