Ohio Medicaid provides coverage for orthodontic treatment, but the circumstances under which it pays for braces are highly specific and conditional. The state’s program, which often operates through various Medicaid Managed Care Plans (MCOs), limits this coverage almost exclusively to cases deemed a medical necessity. Patients must meet a strict set of clinical criteria to qualify, and coverage is not provided for cosmetic concerns.
Eligibility and Coverage Under EPSDT
Orthodontic coverage in Ohio is governed by the federal Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit, often called Healthchek in Ohio. This provision requires states to cover medically necessary services for all Medicaid-eligible individuals under age 21. If a young person’s malocclusion (misaligned bite) is determined to be a health problem requiring correction, the treatment must be covered. Coverage is limited to children and adolescents; comprehensive orthodontic treatment is not covered for adults, whose benefits are restricted to emergency dental procedures.
Criteria for Medically Necessary Orthodontics
Coverage for braces is never granted for reasons of appearance; the sole determinant is whether the malocclusion poses a verifiable health risk or functional impairment. Ohio Medicaid utilizes the Handicapping Labio-Lingual Deviation (HLD) Index, specifically the Ohio Modification Score Sheet, as the objective tool for this determination. This standardized scoring system assesses the severity of the patient’s dental misalignment.
A patient may automatically qualify for coverage if they present with specific, severe conditions, such as a cleft palate, a craniofacial anomaly, or a deep impinging overbite that causes soft tissue damage. Other automatic qualifiers include a severe traumatic deviation from an injury or an extreme overjet (protrusion) measuring 9 millimeters or greater. If an automatic qualifier is not met, the patient must achieve a minimum qualifying score on the HLD Index.
The HLD index assigns points to various elements of malocclusion, including reverse overjet, open bite, and anterior crowding. To qualify under this scoring system, the patient must achieve a total score of 26 points or more. Treatment may also be considered if the malocclusion is documented by a medical professional to exacerbate an underlying medical condition, such as chronic pain, malnutrition, or a speech pathology.
Navigating Prior Authorization and Appeals
Once an orthodontist determines that a patient meets the clinical necessity criteria, the administrative process begins with a request for Prior Authorization (PA). The orthodontist submits a comprehensive package of documentation to the patient’s Managed Care Organization (MCO) or the Ohio Department of Medicaid. The PA process ensures the proposed service is medically necessary and appropriate before treatment begins.
This submission must include:
- A completed HLD evaluation form.
- Diagnostic records like X-rays (including a cephalometric film and tracing).
- Intraoral photographs.
- Dental models of the teeth.
If the MCO denies the initial request for coverage, the patient has the right to appeal the decision. The denial notice specifies the exact reason for the refusal and outlines the steps for filing an appeal. Patients can pursue an internal appeal with their MCO. If that is unsuccessful, they can request a State Hearing for an external review of the decision, which provides an opportunity to present additional medical evidence.
Locating Medicaid-Accepting Orthodontists
Finding a provider who accepts Ohio Medicaid for specialized services like orthodontics can be challenging, as not all practices participate. Patients must first identify their specific Ohio Managed Care Plan (MCO), such as CareSource, Buckeye Health Plan, or Molina Healthcare. Each MCO maintains an online provider directory that lists participating orthodontists within its network. It is advisable to check the directory of the specific plan before scheduling a consultation to ensure the practice is in-network.
The official Ohio Department of Medicaid website also offers a “Find a Provider” search tool to help locate participating dental specialists. Families having difficulty locating a provider or navigating their options can contact the Ohio Medicaid Consumer Hotline for assistance.