Does Apple Health Cover Orthodontics? HLD Score, Age, and Prior Authorization

Washington’s Apple Health does cover orthodontics, but only for clients age 20 and younger, only with prior authorization, and only when the treatment is medically necessary for a qualifying condition. Adults 21 and older are not covered for braces under any circumstance, and cosmetic cases are not covered at any age.¹

Who Qualifies by Age

Orthodontic coverage is available to clients age 20 and younger who are enrolled in a benefit package that includes orthodontic services.¹ The cutoff is strict. Once a client turns 21, any further orthodontic treatment becomes the client’s financial responsibility, even if the braces were placed before that birthday.²

There is no adult exception for trauma, severe bite problems, or disability. The age rule applies regardless of the underlying condition.

What Conditions Apple Health Will Cover

Crooked teeth alone are not enough. For a child or young adult to qualify, the case has to fall into one of these categories:¹

Cleft lip, cleft palate, or cleft lip with alveolar process involvement. Treatment has to be managed by an HCA-recognized craniofacial team that includes at least a dentist, an orthodontist, and an oral maxillofacial surgeon or specialist.
Craniofacial anomalies such as hemifacial microsomia, craniosynostosis syndromes, Treacher Collins syndrome, Marfan syndrome, ectodermal dysplasia, and achondroplasia.²
Severe handicapping malocclusions, which require a score of 25 or higher on the Washington Modified Handicapping Labiolingual Deviation (HLD) Index, plus established caries and plaque control.
Other malocclusions, reviewed case by case through prior authorization.

Cosmetic orthodontics are excluded. Orthodontics as a first-line fix for speech problems, mental health conditions, or sleep apnea is also excluded unless a medical specialist treating that condition has specifically diagnosed it and recommended orthodontic treatment.³

How the HLD Score Works

For malocclusion cases without a diagnosed craniofacial condition, the HLD Index is the gate. The treating orthodontist or dentist fills out HCA form 13-666, and the Health Care Authority makes the final call based on the records submitted.¹ A score of 25 or above is required.

Points come from measurable conditions on permanent natural teeth. Mandibular protrusion is measured in millimeters and multiplied by five. Open bite is measured and multiplied by four. Ectopic eruption counts three points per affected tooth, excluding wisdom teeth. Anterior crowding scores five points per arch when the arch length deficiency is 3.5 millimeters or more, capped at ten points across both arches. Posterior unilateral crossbite scores four points per side when it involves two or more adjacent teeth and at least one permanent molar. When both crowding and ectopic eruption show up in the front of the mouth, only the more severe one can be scored.⁴

What Treatment Is Covered

When prior authorization is granted, Apple Health pays for several categories of orthodontic work, each with its own time limit:¹

Interceptive treatment to reduce the severity of a developing problem.
Limited treatment for a specific issue, capped at 12 months from appliance placement and approved only for transitional or adolescent dentition.
Comprehensive treatment for adolescent dentition, which must be completed within 30 months of appliance placement.
Appliance removal as a standalone service, but only when a different provider originally placed the appliance.

Fixed appliances, meaning traditional braces, are the standard the program pays for. Clear aligners and other removable systems are not covered through the normal authorization path. A provider who wants to use removable appliances has to submit an Exception to Rule request and show the alternative is medically necessary, cost-effective, and that standard covered services would not work for the patient.⁵

Services have to be performed by an orthodontist, pediatric dentist, general dentist, or a provider on an HCA-recognized craniofacial team. Cleft and craniofacial cases specifically require the craniofacial team.²

Getting Prior Authorization

Nearly all orthodontic services require prior authorization before treatment begins, and the provider, not the family, submits the request. The package includes a case study and treatment plan with photos, study casts, and X-rays. A panoramic X-ray is required for impacted-tooth cases. A cephalometric image is required when there is a negative overjet.⁶ HCA form 13-666 goes in with the request to document the HLD score.

If the main reason for treatment is an underlying medical condition such as sleep apnea or a speech disorder, the file must also include a current recommendation from the medical specialist treating that condition. “Current” means within the past 12 months. The recommendation has to call specifically for orthodontic treatment, and the provider has to include the relevant medical diagnostic records, including evidence of other therapies that were tried and did not resolve the problem.³

Cleft and craniofacial cases can use an expedited prior authorization pathway with specific codes for the pre-orthodontic visit, initial limited treatment placement, and follow-up periods. Cases that don’t meet the expedited criteria still have to go through the standard review.¹

If the Request Is Denied

A denial from the Health Care Authority or a managed care plan can be appealed by the patient, parent, or guardian. For children under 21, the correct path is an appeal rather than an Exception to Rule request.⁷

Start with a written appeal to the health plan, following the instructions in the denial letter. Attach any medical evidence that supports medical necessity, and ask the treating providers for supporting letters. Urgent cases can be filed as expedited appeals, and the plan has to decide within 72 hours. To keep any currently authorized care going during the appeal, the appeal has to be filed within 10 days of the denial notice.

If the plan upholds the denial, the next step is an administrative hearing through the state Office of Administrative Hearings, where an independent judge reviews the case. Hearing requests can be made in writing or by phone. An unfavorable hearing decision can be taken to the Board of Appeals, and then to Superior Court within 30 days of the Board’s decision.⁷

Exclusions Families Get Caught By

Even when a child qualifies, several limits apply:¹

Cosmetic treatment is never covered.
Any treatment after the client’s 21st birthday is the client’s responsibility, even if the braces are already on.
Out-of-state treatment is not covered, except from providers in HCA-designated bordering cities.
Limited treatment is capped at 12 months and comprehensive treatment at 30 months, both measured from appliance placement.
Panoramic X-rays are covered once every three years; additional images need prior authorization.
If a client transfers care and the original condition didn’t meet HCA criteria, continued treatment is not covered.

Clients 20 and younger who need something outside the standard rules may still have a path through the federal Early and Periodic Screening, Diagnosis and Treatment program, which can require state Medicaid programs to cover medically necessary services for children even when those services sit outside the standard benefit package. These requests go through HCA review.²

Finding an Orthodontist Who Takes Apple Health

Not every orthodontist participates in Medicaid, so finding one is often the practical hurdle. The Health Care Authority’s “Find a Provider” tool sits under the “Use my coverage” menu on its website.⁸ DentistLink, a free nonprofit referral service run by the Arcora Foundation in partnership with HCA, offers an online directory and reachable referral specialists by phone or text at 844-888-5465 on weekdays. The service can also help with transportation to appointments and interpretation.⁹

1
Washington State Health Care Authority. Orthodontic Services Billing Guide (January 2025)
2
Washington State Health Care Authority. Orthodontic Services Billing Information
3
Washington State Health Care Authority. Orthodontic Prior Authorization Documentation Requirements
4
Washington State Health Care Authority. Orthodontic Information Form (HCA 13-666)
5
Washington Law Help. Exception to Rule for Washington Apple Health
6
Washington State Health Care Authority. Orthodontic Services Billing Guide (October 2025)
7
Washington Law Help. Appeal a Denial From Your Health Plan
8
Washington State Health Care Authority. Find a Provider
9
DentistLink. DentistLink Home