Does SC Medicaid Cover Braces? A Factual Look

This article provides factual information on South Carolina Medicaid’s coverage for orthodontic treatment, specifically braces. Understanding the state’s policies can clarify service availability.

Medicaid Coverage for Braces in South Carolina

South Carolina Medicaid, known as Healthy Connections, covers orthodontic services, including braces. This coverage is primarily for beneficiaries under 21 years of age, with treatment needing completion before their 21st birthday. Coverage is specifically for medically necessary conditions, not cosmetic improvements.

Braces are covered when they address significant functional impairments impacting oral health, speech, or overall well-being. Adult coverage through Healthy Connections is rare and limited to specific, severe circumstances. These cases are typically restricted to situations involving trauma, cancer, or preparation for major surgeries like organ transplants, and generally do not include comprehensive orthodontic treatment.

Understanding Medical Necessity Criteria

For orthodontic treatment to be considered medically necessary under South Carolina Medicaid, specific conditions must severely impact the individual’s health or oral function. The state’s Medicaid program uses the Handicapping Labio-Lingual Deviation (HLD) index, a standardized assessment tool, to evaluate malocclusion severity and determine coverage eligibility.

Qualifying conditions include severe malocclusion, such as deep impinging overbites causing soft tissue damage, anterior crossbites with gingival recession, or severe traumatic deviations. An extreme overjet (protrusion of upper teeth) of 9 millimeters or more, or a reverse overjet (underbite) of 3.5 millimeters or more, are automatic qualifiers. Certain craniofacial anomalies, like a cleft palate, also automatically qualify. Generally, an HLD score of 30 points or more indicates medical necessity, though some conditions qualify regardless of the score.

The Coverage Approval Process

The approval process for orthodontic coverage through South Carolina Medicaid begins with an initial dental examination by a general dentist, who may refer to an orthodontist. It is important to consult with an orthodontist who accepts South Carolina Medicaid.

Once selected, the orthodontist conducts a comprehensive evaluation, including diagnostic records like radiographs and photographs. They then prepare a detailed treatment plan and submit a pre-authorization request to DentaQuest, the dental vendor for South Carolina Healthy Connections. This request must include the completed HLD Assessment form, a narrative justifying medical necessity, and all supporting diagnostic documentation.

Medicaid reviews the information to determine if medical necessity criteria are met. The patient and provider then receive notification of approval or denial. If denied, there may be an option to appeal the decision.

Locating an Orthodontic Provider

Finding an orthodontist who accepts South Carolina Medicaid is a practical step. A primary method is using the DentaQuest website, the dental plan administrator for Healthy Connections. Their online tool allows users to find participating dentists and orthodontists.

Alternatively, contact DentaQuest customer service for a provider list. Asking for referrals from a primary care physician or general dentist is another helpful approach. Always verify that the chosen orthodontist accepts South Carolina Medicaid before initiating evaluations or treatment to ensure coverage.