Does Medicaid Cover Braces in Colorado?

Medicaid, a joint federal and state program, provides healthcare coverage to eligible low-income individuals and families across the United States. In Colorado, this program is known as Health First Colorado. It offers a range of medical services. While Health First Colorado covers various dental services, including preventive and restorative treatments, coverage for orthodontics like braces is subject to specific criteria. Coverage often depends on medical necessity, distinguishing cosmetic treatments from those required for health.

Medicaid Eligibility in Colorado

Health First Colorado extends healthcare coverage to various groups of Coloradans who meet specific income and household size requirements. Eligibility generally includes low-income adults, pregnant individuals, children, and families. For instance, adults under 65 may qualify with household income up to 138% of the Federal Poverty Level (FPL). Pregnant individuals and children typically have higher income thresholds, with children up to age 18 potentially qualifying with household income up to 147% of the FPL, and pregnant women up to 200% of the FPL.

The Modified Adjusted Gross Income (MAGI) methodology is used to determine income eligibility for many Health First Colorado applicants, with a 5% income disregard applied for children, pregnant women, and non-elderly adults. Individuals receiving Supplemental Security Income (SSI) or Temporary Assistance to Needy Families (TANF) may automatically receive Health First Colorado benefits. Applicants can find detailed income guidelines and apply through the Colorado Program Eligibility and Application Kit (PEAK) system. Applications can also be submitted by phone or at local county offices.

Criteria for Orthodontic Coverage

Health First Colorado provides orthodontic benefits, or braces, for children aged 20 and younger, but only when deemed medically necessary. This means coverage is not for cosmetic purposes, such as simply improving a smile, but rather for severe conditions that impair oral function or overall health. The program specifically covers orthodontic treatment for a “severe handicapping malocclusion,” which refers to a significant misalignment of teeth and jaws.

To determine medical necessity, Health First Colorado utilizes a specific set of criteria outlined in the Colorado Orthodontic Criteria Index Form. This index assesses various conditions, including deep impinging overbites, skeletal anterior open bites, large anterior-posterior discrepancies (Class II and Class III malocclusions), and significant crowding of teeth (e.g., greater than 7mm in either arch). Other qualifying conditions might include impacted incisors or canines that require intervention to erupt, or severe posterior crossbites involving multiple teeth.

A comprehensive dental examination and a referral from a general dentist are usually the initial steps to assess whether a child’s condition meets these medical necessity criteria. Orthodontists must document the severe handicapping malocclusion, and this documentation is then submitted for a prior authorization review.

Accessing Orthodontic Care

For Health First Colorado recipients, obtaining care begins with a visit to a general dentist. This dentist must accept Health First Colorado, and they serve as the initial point of contact for all dental needs. Members can locate in-network dentists through the Health First Colorado provider search tool or by contacting DentaQuest, which manages dental benefits for the program.

If the general dentist suspects that a severe malocclusion requiring orthodontic intervention is present, they will typically refer the patient to an orthodontist who also accepts Health First Colorado. The orthodontist will then conduct a thorough evaluation, which often includes taking photos and X-rays to gather the necessary documentation. This information is crucial for demonstrating medical necessity according to the Colorado Orthodontic Criteria Index.

The orthodontist will then submit a Prior Authorization Request (PAR) to DentaQuest, seeking approval for the proposed orthodontic treatment. This prior authorization process ensures that the treatment aligns with Health First Colorado’s medical necessity guidelines before services are rendered. A determination on the request is typically provided within four to six weeks. Once approved, the orthodontic treatment can proceed, with services covered for eligible child members aged 20 and younger.