South Carolina Medicaid, known as Healthy Connections, offers coverage for orthodontic treatment, but coverage for braces is highly conditional. It is strictly limited by age and the medical severity of the dental condition. Recipients must meet specific clinical standards demonstrating the malocclusion is severe enough to affect health or function, not merely cosmetic appearance. Obtaining coverage requires navigating a mandatory process of documentation and prior authorization through the state’s system.
Coverage Under Federal Mandate
Coverage for braces for children stems from a federal requirement known as the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit. This mandate requires state Medicaid programs to cover comprehensive and preventive health care services for all members under the age of 21. Medically necessary orthodontic services fall under the scope of this provision, even if they are not explicitly listed in the state’s standard Medicaid plan.
This coverage is strictly limited to individuals aged 20 and younger, and the entire orthodontic treatment must be completed before the recipient turns 21. For adults aged 21 and over, Healthy Connections does not cover braces or comprehensive orthodontic treatment. Adult dental benefits are limited and generally focus on restorative services like cleanings, fillings, and extractions, with a yearly maximum benefit that excludes orthodontics.
Establishing Clinical Need for Orthodontic Care
For a child to receive coverage, the orthodontic condition must be determined to be a “medical necessity,” meaning the issue significantly impairs the patient’s health or ability to function. Cosmetic issues, such as minor crookedness or spacing, do not qualify for coverage under the program. To standardize this determination, the South Carolina Department of Health and Human Services (SCDHHS) utilizes the Handicapping Labio-Lingual Deviation (HLD) Index.
This scoring system evaluates the severity of the malocclusion based on various clinical measurements. A total score of 30 points or higher on the HLD Assessment form is required to establish medical necessity for comprehensive orthodontic treatment. Certain severe conditions are considered “automatic qualifiers,” meaning they bypass the scoring requirement and are immediately deemed handicapping. Examples of these automatic qualifiers include a severe overjet of 9 millimeters or more, a mandibular protrusion exceeding 3.5 millimeters, or the presence of a craniofacial anomaly like a cleft palate. The HLD Index ensures that only the most functionally impairing conditions are approved for treatment.
Steps for Obtaining Treatment Approval
The process for a Healthy Connections recipient to obtain treatment approval is formalized and requires a series of sequential steps, beginning with a visit to a general dentist. The general dentist must confirm the patient has completed all necessary restorative dental work and maintains good oral hygiene before orthodontic treatment can be considered. The patient is then referred to an orthodontist who participates in the South Carolina Medicaid network.
The orthodontist is responsible for performing the clinical assessment, including the HLD Index scoring, and compiling a comprehensive submission packet. This packet must contain documentation, including diagnostic records such as dental models, intraoral and extraoral photographs, and a cephalogram (a specific type of X-ray) with an embedded scale. This packet is then submitted to SCDHHS’s dental administrator for mandatory Prior Authorization (PA).
The Prior Authorization request is reviewed by a dental consultant to verify that the clinical criteria, primarily the HLD score and supporting records, meet the state’s standard for medical necessity. If the request is approved, the orthodontist receives an authorization number, and treatment can begin. If the request is denied, the recipient or guardian has the right to appeal the decision.