State-funded health coverage, primarily administered through Medicaid and the Children’s Health Insurance Program (CHIP), provides health services to low-income adults, children, and families. State coverage for orthodontic treatment, such as braces, is not guaranteed and is subject to strict conditions and significant variation from one state to the next. The decision to cover braces is almost entirely dependent on whether the treatment is considered medically necessary, not cosmetic.
Eligibility Standards for Minors
Federal law mandates that all children and adolescents under the age of 21 enrolled in Medicaid receive a comprehensive set of benefits through the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program. The EPSDT mandate requires states to provide any treatment necessary to “correct or ameliorate” defects or illnesses discovered during a screening. This provision is the basis for orthodontic coverage for minors, ensuring that dental services go beyond just emergency care or tooth restoration.
To qualify for coverage, the child’s orthodontic condition must be classified as a “severe physically handicapping malocclusion,” meaning it significantly impacts their overall health or function. This necessity is defined by problems that interfere with the ability to eat, speak, or breathe normally, or conditions like a cleft palate or severe traumatic deviations. Orthodontic treatment sought only for straightening teeth to improve appearance is not covered under this standard.
Many state Medicaid programs use objective scoring systems to measure the severity of the malocclusion, often employing the Handicapping Labio-Lingual Deviation (HLD) Index. This index assigns numerical scores based on measurements of tooth misalignment, such as overjet, open bite, mandibular protrusion, and crowding. To qualify for coverage, a patient’s score must meet or exceed a state-determined threshold, which is often 26 points.
The HLD index includes specific criteria that automatically qualify a case, such as a severe impinging overbite where the lower front teeth are destroying the soft tissue of the palate. Other conditions like a cleft palate are also considered automatic qualifiers due to the severe functional impairment they cause.
The Prior Authorization Process
Before any orthodontic treatment can begin, the state insurance program requires Prior Authorization (PA) or Pre-Approval, a formal administrative procedure that serves as the official review to determine if the patient’s condition meets the state’s medical necessity criteria established by the HLD score or other state-specific standards. Without this approval, the state will not provide reimbursement for the cost of the braces.
The treating orthodontist submits a detailed request packet to the state Medicaid office or its designated third-party reviewer. This packet must include comprehensive documentation that clinically supports the necessity of the treatment. Required documents typically involve:
- Current X-rays.
- Clinical photographs of the patient’s mouth and face.
- Diagnostic plaster models or digital scans of the teeth.
- A detailed treatment plan outlining the proposed procedures.
State reviewers, often consulting dentists or orthodontists, examine this documentation to verify the HLD score and confirm that the condition is a functional handicap. The prior authorization process ensures that public funds are used exclusively for health-related care and not for cosmetic procedures. This review process can take several weeks, and the treatment cannot be scheduled until a formal approval letter is issued.
If the prior authorization request is approved, the decision is often valid for a limited period, typically one year, meaning treatment must commence within that timeframe. If the request is denied, the patient’s family has the right to appeal the decision through a formal administrative process. The appeal often requires the orthodontist to provide additional evidence and further justification for the medical necessity of the proposed care.
Coverage for Adult Recipients
Coverage for orthodontic care under state insurance is significantly more restrictive for adults aged 21 and over compared to minors. The federal EPSDT mandate that drives coverage for children does not apply to adult beneficiaries. Consequently, routine orthodontic treatment for adults, including most cases of misaligned teeth or bite problems, is almost never covered by Medicaid.
Adult coverage is typically limited to cases where braces are an integral and necessary part of a much larger, medically essential surgical procedure. The most common exception involves pre-surgical orthodontics required for orthognathic surgery, which is corrective jaw surgery. In these complex cases, braces are necessary to align the teeth into the correct position so the surgeon can successfully reposition the jawbones.
Other highly specific exceptions may include treatment following severe facial trauma or care required as part of reconstructive surgery after the removal of a tumor or cancer. In these instances, the orthodontic care is not for the malocclusion itself but is a reconstructive step to restore basic oral function. The approval process for adults is very strict, demanding extensive medical documentation to prove functional necessity.