Health Care Reform and Dental

About Medically Necessary Orthodontic Coverage

Here's How It Works:

Your dentist will evaluate your child and complete a form that scores the degree of severity of the medical condition. Using a scoring system called the “Handicapping Labio-Lingual Deviation” (HLD) Index, the dentist will rate your child’s condition. A score of 22 or higher qualifies for coverage.

You can access the form from 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 Altus 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 treatment.

Coverage for medically necessary orthodontics is another key element of the Pediatric Dental Essential Health Benefit. This unique benefit provides orthodontic services for children with serious orthodontic impairment resulting from congenital abnormalities that affect their daily ability to function, (e.g. eating, speaking, etc.). Under the provisions of the Affordable Care Act (ACA), there are no lifetime or annual maximum limitations for medically necessary orthodontic procedures, which are covered at 50%.

How do I find out if my child’s condition qualifies for medically necessary orthodontic coverage?
Your child’s dentist will evaluate your child’s condition, helping you to 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 Altus Dental prior to obtaining orthodontic services, no payment will be made after treatment is received.

To learn more, view our Guidelines.