![]() Cast analysis alone frequently indicates that there is no need for orthodontic treatment however, a visual assessment would have a different outcome.ĭespite the EPSDT and Medicaid initiatives, which predicate federally required coverage, there are income, racial, ethnic, cultural, and geographic barriers limiting access to specialty dental care, including orthodontics. Use of study cast analysis only to determine treatment need may not give a clear picture of an existing visual deformity. These include the Handicapping Labiolingual Deviation (HLD) Index ( 14), Peer Assessment Rating Index ( 15), and the HLD (CalMod) Index ( 16). Some states use indices that lack an esthetic component and rely purely on study cast analysis. Examples of these indices are the Index of Complexity, Outcome and Need ( 11), Salzmann Index ( 8), Dental Aesthetic Index ( 12), and the Index of Treatment Need ( 13). Some states use indices that include an esthetic component in addition to the study cast analysis. This raises the concern that patients in need are being disqualified from receiving treatment due to tightened state budgets.Įsthetic components of a malocclusion may or may not be considered by reviewers when determining cases to approve for funding. Moreover, states continue to alter criteria for funded care the state of Iowa, for example, recently increased the case complexity required for approval, thus decreasing the number of cases funded per budget year ( 10). With no standardization for determining qualified cases, disparity exists in orthodontic Medicaid case approvals. Various malocclusion indices, sometimes with modifications, are used by states to serve their populations while meeting budget needs. Since state budgets require funding decisions, most states still use an index as a qualifying criterion to define a handicapping malocclusion. However, this decision was rescinded in 1985, with the AAO opposing the use of any index or classification system to determine orthodontic treatment need ( 9). The American Association of Orthodontists (AAO) has defined medically necessary orthodontic care as “the treatment of a malocclusion (including craniofacial abnormalities/anomalies) that compromises the patient’s physical, emotional or dental health.” ( 7) The AAO originally selected the Salzmann index ( 8) as an objective qualifier for treatment funding for handicapping malocclusions. Consequently, the provision of Phase I treatment can present a conundrum regarding qualification for funding. ![]() ![]() However, such early orthodontic treatment may also improve a patients’ malocclusion enough to no longer have a handicapping malocclusion and thus be disqualified from receiving definitive orthodontic care. Improvements resulting from Phase I treatment can recategorize patients from the medically necessary category to the elective category, requiring less time and cost to treat ( 5, 6). Interceptive orthodontics, sometimes referred to as early orthodontics or Phase I treatment, has been shown to significantly reduce malocclusion severity in a comparison of Medicaid and private-pay populations ( 4). A task force convened in 1966 recommended “treatment of malocclusion with priority provided for interceptive service and disfiguring or handicapping malocclusions” ( 2). ![]() When Medicaid began in 1965, the American Dental Association (ADA) worked collaboratively with federal organizations to help define covered procedures and favored a national dental health program for children. There is a federal ceiling on income eligibility to limit expansion of the program beyond its original scope. Consequently, there is wide disparity throughout the United States regarding Medicaid coverage of orthodontic treatment. With Medicaid financed half by the federal government and half by state government, it is at the discretion of individual states to define the term handicapping malocclusion. Handicapping malocclusions were deemed eligible for Medicaid funding. The Early and Periodic Screening, Diagnosis, and Treatment Program (EPSDT), established in 1967, is a component of Medicaid that provides preventive services and treatment for children and mandates access to orthodontic treatment for Medicaid eligible patients ( 3). Orthodontics, although not specifically listed, was included with dental care ( 2). Title XIX listed certain medical services that states could fund with federal sharing. Title XIX of the Act, commonly known as Medicaid 1965 ( 2), was developed to provide healthcare coverage to the medically indigent. The Social Security Act was signed by President Lyndon Johnson in 1965. Medicaid funding for orthodontic services is a multifaceted issue with programmatic variation among states that can influence where orthodontists practice and who and how they treat.
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