Medicaid is a joint federal and state program providing health coverage to millions of Americans with limited income. Orthodontics, or teeth straightening, is a specialized dental service that corrects malocclusion (improper alignment of the teeth and jaws). While Medicaid covers medically necessary services, coverage for teeth straightening is highly restricted because it is often viewed as cosmetic. The specific rules and limitations for orthodontic coverage vary significantly by state, making it a complex issue for beneficiaries.
Coverage for Children and Teens
Children and adolescents under the age of 21 have the highest likelihood of receiving Medicaid coverage for orthodontic treatment. This eligibility is based on the federal Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit. EPSDT requires states to provide comprehensive health services, including dental care, to correct or improve physical and mental conditions discovered during routine screenings.
Federal law mandates that states must cover all necessary treatment for children, even if the service is not specifically listed in the state’s Medicaid plan. If a dental screening identifies a severe malocclusion, the state is obligated to provide the necessary orthodontic treatment. Coverage is not automatic for all cases of misaligned teeth; the treatment must be proven necessary rather than an elective cosmetic procedure. Orthodontic services must minimally include relief of pain and infections, restoration of teeth, and maintenance of dental health.
Defining Medical Necessity
Medicaid excludes coverage for treatments considered purely cosmetic, including most minor teeth straightening procedures. Coverage is limited to severe malocclusions that cause significant functional impairment. These impairments typically involve problems with chewing, speaking, or conditions that compromise the health of the teeth, gums, or jaw structures.
Many states use standardized, objective scoring systems to quantify the severity of the dental condition and justify coverage. The Handicapping Labio-Lingual Deviation (HLD) Index is one of the most common scoring tools used by state Medicaid agencies. This index measures specific deviations from normal alignment, such as severe overjet, open bite, or mandibular protrusion.
A patient’s malocclusion must achieve a minimum score on the HLD Index or an equivalent state-adopted system to be considered for coverage. For example, a condition like a cleft palate or severe traumatic deviation automatically qualifies as a handicapping malocclusion, often receiving a maximum score. This quantitative approach helps ensure that approved cases demonstrate the greatest physical need, differentiating them from less severe cases of misalignment.
Adult Coverage Limitations
For adults aged 21 and older, Medicaid coverage for routine orthodontic treatment is not provided. States have considerable flexibility in determining what, if any, dental benefits are offered to adult beneficiaries, and most choose to exclude elective or comprehensive teeth straightening. Most adults seeking braces for standard misalignment issues will find that the procedure is not covered.
Exceptions for adult orthodontic coverage are linked to severe medical conditions requiring complex surgical correction. Coverage may be approved when teeth straightening is an integral part of a broader treatment plan involving orthognathic surgery. This surgery corrects severe skeletal malformations resulting from congenital defects, trauma, or pathology, such as an extreme jaw discrepancy.
In these limited cases, the orthodontic work is considered medically necessary because it prepares the jaw and teeth for the surgical procedure that addresses the underlying skeletal pathology. If the proposed treatment is not part of a surgical correction for a severe health-impacting condition, the request for adult orthodontic coverage will almost certainly be denied. Some states further limit adult dental benefits to emergency procedures that treat fractures or eliminate acute infection.
The Prior Authorization Process
All orthodontic services under Medicaid, even for children who meet medical necessity criteria, require Prior Authorization (PA). This process is mandatory and must be completed by the treating orthodontist before any treatment begins. The purpose of the PA is to allow the state Medicaid agency to review the case and confirm that the proposed treatment meets established medical necessity standards.
The orthodontist must submit a comprehensive package of diagnostic records to the state. This typically includes X-rays, plaster or digital models of the teeth, intraoral photographs, a detailed treatment plan, and the completed severity score sheet. This documentation must clearly demonstrate the functional impairment and quantify the severity of the malocclusion according to the state’s criteria. The state’s clinical review team then assesses the submission and issues a determination within a set number of business days.
If the prior authorization request is denied, the patient or the patient’s guardian will receive a written notice explaining the reason for the adverse determination. Beneficiaries have the right to appeal this decision, which involves submitting a formal request for reconsideration, often with additional clinical justification from the orthodontist. The appeal process is a formal opportunity to challenge the initial denial, but it is still subject to the same strict medical necessity requirements.