Medicaid is a joint federal and state program providing healthcare coverage to low-income adults, children, and people with certain disabilities. Orthodontic treatment, which typically involves braces or aligners, is not a standard, guaranteed benefit across all Medicaid plans. Coverage depends heavily on the patient’s age and whether the treatment is deemed medically necessary rather than purely cosmetic. Unlike basic dental care, which is generally covered for children, orthodontic coverage is restricted and varies significantly based on the recipient’s state of residence.
Federal Requirements for Coverage of Children
The federal government mandates comprehensive coverage for all Medicaid-eligible individuals under the age of 21 through the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit. EPSDT ensures children receive timely screening, diagnostic, and treatment services needed to correct or ameliorate physical and mental conditions. This mandate explicitly includes medically necessary orthodontic services, even if those services are not covered under the state’s standard Medicaid plan for adults.
The federal standard requires states to provide any necessary health care service discovered during a screening. Once a potential problem with a child’s bite or alignment is identified, the state must cover the treatment if it is determined to be medically necessary to prevent or correct a health condition. While the federal law mandates coverage, states retain flexibility in defining “medically necessary” for orthodontics, which creates variation in approval rates across the country.
Criteria for Medically Necessary Orthodontics
Orthodontic coverage under Medicaid is limited to cases involving a functional impairment, not aesthetic reasons. The purpose of covered treatment is to correct a severe malocclusion, or bad bite, that negatively impacts a person’s oral health, or ability to speak, chew, or breathe. Examples of covered issues include severe crowding that prevents proper cleaning, significant jaw discrepancies, or a deep impinging overbite where the lower front teeth bite into the gum tissue behind the upper teeth.
To quantify the severity of a condition and determine eligibility, most state Medicaid programs use standardized assessment tools. The Handicapping Labio-Lingual Deviations (HLD) Index is a common scoring system used to measure how much a case deviates from a normal bite. A patient must typically score above a specific threshold on the HLD Index, often 26 points, or present with an “auto-qualifying” condition to be considered for coverage.
Auto-qualifying conditions are severe malocclusions that automatically meet the medical necessity threshold. These include cleft palate deformities, an overjet exceeding a certain millimeter measurement, or impacted permanent teeth that require surgical intervention. The HLD Index provides an objective, quantitative score, serving as a screening tool to measure the severity of the malocclusion. The state’s specific threshold score and the list of auto-qualifiers ultimately determine whether the treatment is covered.
Coverage Limitations for Adults
For individuals aged 21 and older, orthodontic coverage is significantly more restrictive because the EPSDT mandate no longer applies. Most state Medicaid programs do not cover routine orthodontic care for adults, even if the malocclusion is severe. Standard adult dental benefits typically focus on emergency care, pain relief, and basic maintenance, not comprehensive orthodontic correction.
If adult coverage exists, it is generally reserved for specific, medically complex cases where the orthodontic treatment is an integral part of a broader medical or surgical necessity. Examples include preparing the teeth for corrective jaw surgery (orthognathic surgery) necessary to treat a severe congenital defect, trauma, or disease. In these rare instances, the braces are considered a required phase of the overall medical treatment plan, not a standalone dental procedure.
The Administrative Process for Approval
The path to receiving approved orthodontic treatment under Medicaid is procedural and requires prior authorization from the state’s Medicaid office before treatment can begin. The first step involves finding an orthodontist who is an active Medicaid provider and can assess the patient’s condition using state-specific criteria. The orthodontist gathers a comprehensive set of diagnostic records, which typically include dental models, full-mouth X-rays, and a completed form detailing the HLD Index score or other qualifying conditions.
This documentation is submitted to the state for review, a process that can take several weeks. The state’s dental consultants review the materials to confirm the case meets the established medical necessity criteria. If the request is approved, the authorization is valid for a specific period, often one year, and treatment can commence.
If the initial request for prior authorization is denied, the patient or the provider has the right to appeal the decision. This appeal process, sometimes called an Administrative Review or Reconsideration, requires submitting additional information to challenge the denial. The provider may need to submit new evidence or request a peer-to-peer review with the state’s dental consultant to argue for the medical necessity of the treatment.