Medicaid, the government healthcare program for low-income individuals and families, provides coverage for a wide range of medical services. When it comes to orthodontic treatment, Medicaid follows certain guidelines and requirements to determine if a child qualifies for coverage. We offer Medicaid in many of our offices and in this blog post, we will explore the key factors involved in Medicaid’s decision-making process for orthodontic coverage, along with the steps involved and the options available to families.

1. Orthodontic Severity Scoring:
To assess whether a child qualifies for Medicaid coverage for braces, a scoring system is used to evaluate the severity of their orthodontic condition. This scoring is typically conducted by the orthodontist during the new patient exam, where records are taken and a thorough examination is performed. The scoresheet filled out by the orthodontist helps determine if the case should be submitted for Medicaid approval.

2. Oral Hygiene and Dental Examination:
Medicaid requires children to exhibit good oral hygiene and have had a recent dental cleaning and examination by their general dentist within the last six months. This ensures that the child’s overall oral health is in good condition before proceeding with orthodontic treatment.

3. Cavities and X-ray Evaluation:
Children seeking orthodontic coverage through Medicaid must be free of cavities as observed on x-ray films. Additionally, a signed statement from the dentist or orthodontist affirming the child’s ability to successfully complete the orthodontic treatment is required. Exceptions may be made for teeth planned for extraction or those that will be lost soon. The orthodontist will determine if submission for Medicaid approval can be attempted when cavities are present.

4. Review and Decision:
Once the necessary paperwork is completed and submitted to Medicaid, it is reviewed by a Claims Processor. The review process usually takes two weeks or less. Following the review, the orthodontic office will notify the family of the decision. Simultaneously, Medicaid will send the results by mail to the insured party.

5. Collaboration and Payment Options:
If a child’s case doesn’t meet the scoring criteria for Medicaid coverage, the orthodontic office will work closely with the family to provide alternative payment options based on their specific needs. The goal is to ensure that all children can achieve a smile they can be proud of, without finances becoming a barrier. Various finance options can be explored to make orthodontic treatment more affordable and accessible.

Medicaid coverage for orthodontic treatment requires adherence to specific guidelines and scoring criteria. The evaluation process takes into account factors such as oral hygiene, dental examinations, cavity status, and the severity of the orthodontic condition. In cases where coverage is not approved, orthodontic offices often provide alternative payment options to ensure children can still receive the treatment they need. By understanding these requirements and procedures, families can navigate the Medicaid process more effectively and ensure their child’s oral health receives the attention it deserves.