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Medicaid Revises Orthodontic Rule

November 17, 2011

The Board of Directors that oversees Medicaid met on Oct. 8 to consider changes to the rule governing orthodontic services provided to Medicaid patients. Several dentists attended the hearing and commented about the importance of these services. They also commented that the rule as written seemed too vague and asked for further clarification of the acceptance criteria for orthodontic cases.

They reported that it is currently difficult to advise patients with confidence whether or not an orthodontic case will be approved by Medicaid.

Medicaid clarified that the rule is a framework and that they plan to establish additional criteria to bring more clarity to the orthodontic approval process through a stakeholder retreat. In fact, a formal stakeholder meeting on implementation of the adopted policy has been scheduled for early December. Discussion at the stakeholder meeting is expected to include the development of a clear rating system, such as a points system, for approval of orthodontic cases as well as discussion of potential payment changes from a lump sum payment up front to monthly payments, or a similar model. For more information about this stakeholder retreat, please contact CDA Director of Governmental Relations Jennifer Goodrum at 303-996-2847 or This email address is being protected from spambots. You need JavaScript enabled to view it. .

Also, at the rule hearing, it was noted that a change in the rule could potentially broaden the pool of providers who could offer orthodontic services.  Several dentists attending the hearing noted the importance of having a specialist provide the services, especially as cases approved by Medicaid tend to be complex. Medicaid clarified that the intent of this rule change was not to allow any provider to provide any service. Rather additional rules would be developed to clarify which types of dental specialists could provide various covered services (i.e. potentially allowing pediatric dentists to provide some early intervention, orthodontic services).

Medicaid’s Board will meet again Nov. 18 to consider the final adoption of the revised rule. The final proposed rule is available for review by clicking here. If you have any comments or would like additional details about the hearing on Nov. 18, please contact Jennifer Goodrum at 303-996-2847 or This email address is being protected from spambots. You need JavaScript enabled to view it. .



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