Does Illinois Medicaid Cover Braces?

Illinois Medicaid may cover braces for eligible patients under age 21 when the orthodontic condition meets the state’s medical-necessity requirements and treatment receives prior authorization.

Coverage is not based only on whether an orthodontist recommends braces. Illinois uses the Handicapping Labio-Lingual Deviation Index, commonly called the HLD Index, along with several automatic qualifying conditions to determine whether comprehensive orthodontic treatment is covered.

Orthodontic Experts accepts Illinois Medicaid plans at its Illinois clinics. Our clinic staff can verify the patient’s current benefits, complete the orthodontic evaluation and submit the required records for review.

Illinois Medicaid braces coverage at a glance

Who can qualify for Medicaid-covered braces in Illinois?

A patient generally must meet all the following conditions:

• The patient is enrolled in an applicable Illinois Medicaid program and has active coverage.
• The patient is under 21 years old.
• The permanent teeth required for evaluation are sufficiently erupted.
• Necessary general dental treatment is up to date.
• The patient demonstrates good enough oral hygiene to proceed safely with braces.
• The orthodontic condition scores at least 28 points on the Illinois HLD Index or meets an automatic qualifying condition.
• The required records are submitted and prior authorization is approved before braces are placed

These requirements explain why an Illinois Medicaid card does not automatically mean braces will be covered. Eligibility for Medicaid and approval for orthodontic treatment are separate decisions.

What is the Illinois HLD Index?

The Handicapping Labio-Lingual Deviation Index is a clinical assessment used to document the severity of an orthodontic condition.

An orthodontist records qualifying bite and alignment findings using the state’s HLD scoring tool. Illinois Medicaid generally requires a score of 28 or higher unless the patient has an automatic qualifying condition.

The HLD Index is not simply a count of crooked teeth. It evaluates specific clinical relationships and deviations. A patient may clearly benefit from braces but still not reach the state’s coverage threshold.

Families are not expected to calculate an HLD score themselves. Accurate scoring requires an orthodontic examination and the appropriate diagnostic records.

What conditions automatically qualify under the Illinois HLD rules? Actually Decide

Effective January 1, 2025, the Illinois Department of Healthcare and Family Services identifies the following automatic qualifying conditions:

• Cleft palate or another craniofacial anomaly
• A deep impinging bite with tissue damage, rather than teeth merely touching the palate
• An anterior crossbite accompanied by gingival recession
• A severe traumatic deviation caused by circumstances such as an accident or tumor
• An overjet measuring 9 millimeters or more
• Impacted teeth whose eruption is obstructed when extraction is not indicated

An automatic qualifier means the case does not have to reach the standard 28-point HLD score. It does not remove the need for clinical documentation, active eligibility or prior authorization.

The reviewing organization still evaluates whether the submitted records establish that the condition meets the applicable definition.

What does not usually qualify?

Illinois Medicaid does not cover cosmetic dentistry. Braces requested primarily to improve appearance are therefore not covered.

Mild or moderate crowding, spacing or bite irregularities may not meet the state’s threshold, even when orthodontic treatment would improve the smile.

A denial does not necessarily mean the patient has no orthodontic problem. It means the submitted case did not satisfy the Medicaid coverage requirements applied to that request.

Why do oral hygiene and dental treatment matter?

Illinois requires patients seeking Medicaid orthodontic approval to have good oral hygiene and necessary dental treatment up to date.

Braces can make brushing and flossing more demanding. Starting treatment when active cavities, gum inflammation or significant plaque are present may increase the risk of decay, gum problems or permanent marks on the teeth.

Before authorization or treatment, a patient may need to:

• Complete fillings or other required dental care
• Address active tooth decay or gum concerns
• Improve brushing and flossing
• Attend a dental cleaning
• Obtain clearance or updated records when requested

This requirement protects the patient’s oral health during treatment. It is not merely an administrative step.

How does the Illinois Medicaid braces approval process work?

1. Verify the patient’s current coverage

Orthodontic Experts clinic staff identify the patient’s current Illinois Medicaid plan and verify available benefits.

Patients should bring their current plan card and State of Illinois Healthcare and Family Services medical information. Medicaid eligibility can change, so it must be verified before treatment and throughout the course of care.

2. Complete an orthodontic evaluation

The orthodontist examines the teeth, bite, jaw relationship and facial development.

The evaluation determines whether orthodontic treatment is clinically recommended and whether the condition appears capable of meeting Illinois Medicaid requirements.

3. Complete the HLD assessment and diagnostic records

If the case may qualify, the orthodontic team completes the HLD scoring process and gathers the documentation required for prior authorization.

The file may include:

• The completed Illinois HLD scoring tool
• Diagnostic photographs
• Dental models or their digital equivalent
• Appropriate radiographs
• A written clinical narrative
• The proposed treatment plan
• Documentation of an automatic qualifying condition, when applicable

The quality and completeness of this submission matter. Missing or inadequate documentation can delay the review or contribute to a denial.

4. Submit prior authorization

Orthodontic Experts clinic staff submit the authorization request to the organization responsible for the patient’s orthodontic benefit.

The patient or parent does not have to prepare the clinical submission independently.

5. Receive the decision

The reviewing organization may approve treatment, request more information or deny the request.

Orthodontic Experts can communicate the result and explain the next step, but the practice cannot guarantee approval or override the coverage decision.

6. Confirm eligibility before starting braces

Illinois requires prior authorization before braces are placed. The clinic must also confirm that the patient remains Medicaid-eligible before treatment begins.

Prior authorization alone does not guarantee payment if the patient is not eligible on the date a service is provided.

Does Orthodontic Experts require a dentist referral?

Orthodontic Experts does not require a general dentist referral to schedule an orthodontic consultation.

However, an individual Medicaid plan may have its own referral or administrative requirements. Clinic staff can review the patient’s plan information and explain whether another step applies.

Patients should continue seeing a general or pediatric dentist for routine examinations, cleanings and restorative care before and during orthodontic treatment.

Does Illinois Medicaid cover braces for adults?

Illinois Medicaid orthodontic coverage is generally limited to patients under age 21.

Illinois provides certain dental benefits for adults, but that does not mean comprehensive adult orthodontic treatment is covered. An adult Medicaid member should not assume that medically helpful braces qualify under the children’s orthodontic benefit.

If an adult has an unusual traumatic, surgical or craniofacial circumstance, coverage should be checked individually. When Medicaid orthodontic coverage is unavailable, Orthodontic Experts can explain self-pay treatment and applicable financing options.

Does Illinois Medicaid cover Invisalign or clear aligners?

Illinois Medicaid authorizes medically necessary orthodontic treatment rather than a cosmetic appliance preference.

Traditional braces are commonly used for approved comprehensive treatment. Invisalign, other clear aligners, ceramic braces and similar upgrades are not routinely included simply because the patient prefers them.

If an alternative appliance is clinically appropriate but not included in the Medicaid authorization, the patient may be able to pay an approved upgrade difference. This depends on plan rules, member-billing requirements and Orthodontic Experts’ current policies.

No upgrade should be promised until those requirements have been checked.

What does approved orthodontic treatment include?

According to the Illinois Dental Office Reference Manual, comprehensive orthodontic treatment includes more than placing braces.

Approved comprehensive care includes services such as:

• The initial orthodontic examination
• Complete diagnostic records and the clinical narrative
• Necessary fixed or removable appliances
• Adjustments during active treatment
• Repair of broken brackets
• Removal of appliances after active treatment
• Retainers or other necessary retention techniques

Patients who remain Medicaid-eligible should not be charged separately for services already included in the approved comprehensive orthodontic treatment.

Orthodontic coverage is generally limited to one treatment per lifetime. Illinois Medicaid also does not ordinarily cover separate multiphase orthodontic treatment.

Does Illinois Medicaid cover retainers?

Necessary retainers or retention techniques are included in approved comprehensive orthodontic treatment.

That does not mean every future lost, damaged or additional retainer is automatically covered. Replacement coverage can depend on the patient’s eligibility, the circumstances, the applicable plan and whether the requested service falls within the authorized treatment.

Patients should contact their clinic as soon as a retainer is lost, damaged or stops fitting. Prompt attention can reduce the risk of unwanted tooth movement.

What if Illinois Medicaid denies braces?

Beginning January 1, 2025, the dental benefit administrator must provide the submitting provider with the HLD scoring tool and the score used when an Illinois Medicaid orthodontic request is denied.

That information can help the orthodontic team understand whether the denial resulted from:

• An HLD score below 28
• A finding that an automatic qualifier was not established
• Missing or insufficient documentation
• Eligibility or benefit issues
• Another plan-specific reason

Orthodontic Experts staff can review the decision and assist with an appeal when there is an appropriate clinical or administrative basis.

An appeal should address the actual reason for denial. Resubmitting the same information without correcting the issue is unlikely to change the result.

If coverage remains unavailable after review or appeal, families can discuss self-pay treatment and applicable payment options.

Read our complete Medicaid braces denial and appeal guide.

Does Orthodontic Experts accept Illinois Medicaid?

Orthodontic Experts accepts Illinois Medicaid plans at its participating Illinois clinics and is accepting new Medicaid orthodontic patients, subject to current eligibility and authorization.

Plan acceptance does not guarantee that braces will be covered. The patient must still meet the Illinois clinical criteria and receive prior authorization.

Use the [Illinois Medicaid orthodontist guide] to find a participating clinic and learn what to bring to the appointment.

Families searching specifically within Chicago can use our [Medicaid orthodontist in Chicago guide].

What should I bring to the consultation?

Bring the patient’s current Illinois Medicaid or managed-care plan card and the identification normally required for an appointment.

Tell the orthodontic team about any relevant dental or medical history, including:

• Impacted teeth
• Facial or dental trauma
• Cleft palate or craniofacial care
• Previous orthodontic treatment
• Recent dental X-rays
• Pending fillings, extractions or other dental work

The orthodontist will determine which new diagnostic records are necessary.

Start with an orthodontic evaluation

Parents do not need to calculate an HLD score or decide whether their child automatically qualifies before making an appointment.

The orthodontic evaluation establishes what is happening clinically. If the case appears capable of meeting Illinois Medicaid requirements, Orthodontic Experts clinic staff can prepare and submit the required authorization records.

Frequently asked questions