Orthodontic benefit expansion
OHP orthodontic benefit expands to include those under age 21 with handicapping malocclusion.
The Oregon Health Plan (OHP) orthodontic benefit has historically included coverage for patients under age 21 with cleft palate and cleft lip with alveolar process involvement, and more recently certain craniofacial anomalies. Beginning January 1, 2023, the OHP orthodontic benefit has expanded to also include coverage for handicapping malocclusion, providing coverage for orthodontics that might otherwise have been out of financial reach for low-income Oregonians under age 21 with certain health conditions. This brings OHP in line with Medicaid orthodontic benefits of Washington and California.
With this benefit expansion, the Oregon Health Authority is requiring specific documentation for these cases to be considered for approval. Children must be free and clear of decay and periodontal disease as documented by a comprehensive or periodic exam within the prior 6 months. OHA has also adopted the Handicapping Labio-Lingual Deviation (HLD) Index California Modification Score Sheet. The Score Sheet includes the following automatic qualifying conditions:
- Cleft palate, cleft lip with alveolar process involvement, craniofacial anomalies resulting in significant malocclusion expected to result in difficulty with mastication, speech, or other oral function
- Deep impinging overbite when lower incurs are destroying the soft tissue of the palate
- Crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present
- Severe traumatic deviation (e.g., loss of a premaxilla segment by burns or by accident; the result of osteomyelitis; or other gross pathology)
- Overjet >9 mm with incompetent lips and masticatory and speech difficulties
- Reverse overjet >3.5 mm with masticatory and speech difficulties
If the child does not have an automatic qualifying condition, an HLD Index score of 26 is necessary to qualify for the orthodontic benefit.
Additional information on specific requirements for orthodontic referral submission has been disseminated to CareOregon Dental’s network primary dental clinic dental directors. For more information, primary dental providers should contact their clinic’s dental director. Other providers can contact the Dental Access Team at dentalaccessteam@careoregon.org.
