Medicaid Coverage of Orthodontia for Children
Medicaid, EPSDT and Dental Care
The Medicaid program, found in Title XIX of the Social Security Act, is a cooperative state and federal program that covers health care for categories of low-income individuals.1 States have the option of covering dental services for adults through Medicaid.2 Medicaid
requires, however, that all beneficiaries under the age of 21 receive Early and Periodic, Screening, Diagnostic and Treatment (EPSDT).3 EPSDT consists of screening, diagnostic and treatment services.4 In the dental context, children are entitled to dental examinations, as well as diagnosis and treatment of dental conditions, such as dental caries, periodontal disease and malocclusion.
Before authorizing treatment under Medicaid, states determine if medical or dental care is medically necessary. The Medicaid Act requires that EPSDT dental services ?shall at a minimum include relief of pain and infections, restoration of teeth, and maintenance of dental health.?5 Furthermore, the Act explicitly mandates that states provide ?such other necessary health care, diagnostic services, treatment, and other measures . . . to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the State plan.?6 While the Medicaid Act, accompanying regulations and federal guidance provide a great deal of instruction on what services must be covered, states have some flexibility in developing processes to determine whether orthodontia services are medically necessary.
Malocclusion and Orthodontia
Orthodontia is a dental service provided to children and adults with malocclusion, or poor alignment of teeth. Malocclusion can be caused by any number of conditions, including crowding of teeth, overjet, overbite or crossbite.7 It can be inherited or brought on by premature tooth loss, thumb sucking and pacifier use; malocclusion can also develop as children grow older.8 If the malocclusion is severe, children may have difficulty biting and chewing, swallowing, and speaking.9 Additionally, dental-facial impairments may cause psychological damage, with children refusing to interact with peers, withdrawing socially and generally suffering from low self-esteem; if the impairment is extreme, the malocclusion can be considered ?handicapping.?10
While orthodontists frequently provide orthodontia to treat any type of malocclusion in the private market, in the Medicaid context, orthodontia is generally considered to be medically necessary only when children exhibit handicapping malocclusion.11 The State Medicaid Manual by Centers for Medicare and Medicaid Services, which administers the Medicaid program, states, ?Therapeutic Services include . . . [o]rthodontic treatment when medically necessary to correct handicapping malocclusion.?12 However, the Guide to Children?s Dental Care in Medicaid, published by CMS in October 2004, explains that among the dental services to be provided is ?orthodontic treatment when medically necessary to correct handicapping and other malocclusions.?13
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- April 1, 2019
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