Health Care Reform

Medically Necessary Orthodontic Coverage

Here’s how it works

Your dentist will evaluate your child and complete a form that scores the severity of the condition. Using a scoring system called the Handicapping Labio-Lingual Deviation (HLD) Index, the dentist will rate your child’s condition. A score of 28 or higher qualifies for coverage. You can access the form for your dentist here.

Certain conditions – such as a cleft palate or a severe overbite – will automatically qualify for this coverage.

Your dentist will submit the rating form – along with other relevant documentation, such as x-rays and photographs of your child’s mouth – to Delta Dental – so that we can review the treatment plan.

You and your dentist will be notified in writing of our decision to approve or deny coverage for the treatment.

Offering coverage for medically necessary orthodontics is another key element of the Pediatric Dental Essential Health Benefit required under the new health care reform law.

This unique benefit provides orthodontic services for children with serious orthodontic impairment resulting from congenital abnormalities that affect their daily ability to function, like eating and speaking.

Under the provisions of the Affordable Care Act (ACA), there are no lifetime or annual maximum limitations for medically necessary orthodontics procedures, which are covered at 50%.

Does my child’s condition qualify for medically necessary orthodontic coverage? Your child’s condition must be evaluated by a dentist. An orthodontic evaluation will help you determine whether your child will qualify for medically necessary orthodontic services.

Remember, prior authorization is required before you obtain any treatment. If you and your dentist do not request authorization from Delta Dental prior to obtaining medically necessary orthodontic services, then no payment will be made after treatment is received.

To learn more, view our Guidelines.