Does Medi-Cal Cover Braces in California?

Medi-Cal, California’s Medicaid program, provides healthcare services to eligible low-income individuals and families. Integral to this comprehensive system is Denti-Cal, the state’s dental program, which aims to ensure access to essential oral health services. This includes a range of dental treatments, from preventive care like cleanings and exams to restorative procedures such as fillings and root canals. The program also extends its coverage to specialized services like orthodontics, particularly for qualifying children.

Medi-Cal Orthodontic Coverage Criteria

Medi-Cal orthodontic coverage primarily targets beneficiaries under 21 years of age. This coverage is not for cosmetic enhancements but is strictly limited to cases deemed medically necessary.

To determine medical necessity, Denti-Cal utilizes specific assessment tools, such as the Handicapping Labio-Lingual Deviation (HLD) index. A score of 26 points or more on the HLD index typically indicates a handicapping malocclusion that qualifies for coverage. Certain severe conditions may also qualify for authorization without meeting the HLD score threshold.

Examples of conditions that commonly meet Denti-Cal’s medical necessity criteria include severe malocclusions that affect speech, chewing, or overall health. This can encompass craniofacial anomalies, such as cleft palate deformities. Other qualifying issues involve deep impinging overbites where lower incisor teeth damage soft palate tissue, or crossbites where anterior teeth cause soft tissue damage. Severe overjets greater than 9 millimeters and severe traumatic deviations resulting from physical trauma or gross pathology may also be covered.

Locating a Medi-Cal Orthodontic Provider

A primary resource for locating providers is the official Denti-Cal website, specifically its “Find a Dentist” tool, often found on the Smile, California portal. This online directory allows individuals to search for dental specialists, including orthodontists, within their geographical area.

Beneficiaries can also contact their local county health department or their Medi-Cal managed care plan for a list of participating orthodontic providers. Another helpful approach is to ask a current general dentist, if they accept Medi-Cal, for referrals to orthodontic specialists within the network.

When contacting potential orthodontic providers, it is important to confirm they are accepting new Medi-Cal orthodontic patients. It is also beneficial to inquire if they are familiar with and experienced in navigating the Denti-Cal approval process.

The Medi-Cal Dental Customer Service Line, available at 1-800-322-6384, can also provide assistance in locating providers and answering general questions.

The Orthodontic Treatment Approval Process

Once a qualifying patient identifies a Medi-Cal orthodontic provider, the process to secure treatment begins with an initial orthodontic consultation. During this visit, the orthodontist will assess the patient’s condition and gather necessary diagnostic records. These records typically include comprehensive X-rays, clinical photographs, and dental impressions, which are used to create study models of the patient’s teeth.

Following the collection of these diagnostic materials, the orthodontist plays a central role in submitting a Treatment Authorization Request (TAR) to Denti-Cal. This request details the proposed treatment plan and includes the diagnostic records, such as the HLD index score, to demonstrate medical necessity.

Denti-Cal’s dental consultants then review the submitted TAR and supporting documentation to determine if the proposed treatment meets the established medical necessity criteria. The review process can take a variable amount of time, with some cases taking between one to six months for a decision. Possible outcomes of this review include approval of the treatment plan, modification of the plan, or denial of the request. Should a TAR be denied, an appeal process is available to challenge the decision.