Health First Colorado, the state’s Medicaid program, does cover braces in Colorado, but only for members under 21 and only when the orthodontic problem is severe enough to count as medically necessary. For approved cases, the program pays 100% of the cost with no copays, deductibles, or annual limits.1Department of Health Care Policy and Financing. Health First Colorado Children’s Dental Benefits Summary Most denials come down to the severity test, not the family’s eligibility for Medicaid itself.
Who the Coverage Is For
Orthodontic benefits are limited to Health First Colorado members under age 21. This cutoff comes from the federal Early and Periodic Screening, Diagnostic, and Treatment requirement, which obligates state Medicaid programs to provide medically necessary care for children.2eCFR. 42 CFR Part 441 Subpart B – Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) of Individuals Under Age 21
Your child also has to qualify financially. Approximate monthly income thresholds for children aged 0 through 18 run around $1,852 for a household of one, $2,503 for a household of two, $3,154 for three, and $3,805 for four.3Health First Colorado. Do You Qualify These numbers shift periodically, so verify the current figures before counting your family in or out.
Enrollment has to stay active for the entire course of treatment, which usually runs two to three years. If coverage lapses because of an income change, a move out of state, or anything else, the state stops paying for the ongoing work.
The Medical Necessity Test
This is where most requests fail. Health First Colorado does not pay for braces that are cosmetic. The program measures severity with a scoring tool called the Modified Handicapping Labiolingual Deviation Index. The orthodontist records millimeter measurements for overjet, overbite, open bite, crossbite, crowding, and related conditions, and each measurement earns points. A combined score of 26 or higher is generally required to qualify.4DentaQuest. Criteria for Orthodontics – Colorado Health First
Some conditions qualify automatically without needing to clear the point threshold. Cleft palate, cleft lip, and other craniofacial anomalies that interfere with eating, breathing, or speaking fall in this category, along with deep overbites that cause tissue damage and severely impacted teeth. Mild crowding, slight spacing, and other issues that don’t impair function will be denied as cosmetic.
How Approval Works
Your child’s orthodontist handles the submission, but you should know what goes into it. The provider pulls together panoramic and cephalometric X-rays, clinical photographs of the teeth and face, dental impressions or digital models of the bite, and a completed HLD Index form with every measurement in millimeters. A single miscalculation or missing image is enough to trigger a rejection.
The orthodontist has to participate in the DentaQuest provider network, which administers dental benefits for Health First Colorado.5Department of Health Care Policy and Financing. Health First Colorado Dental Benefits If the orthodontist you’ve been seeing doesn’t accept Health First Colorado, you’ll need to find one who does before any of this starts. DentaQuest’s provider search tool or member services line can point you to participating offices.
Once the packet is complete, the office submits a prior authorization request to DentaQuest through their electronic portal. DentaQuest reviews the clinical data, cross-checks the HLD measurements against the X-rays and photos, and issues a decision. Both you and the provider receive the notice. An approval letter specifies the billing codes and a timeframe for starting work. Any later change to the treatment plan, like switching from traditional braces to a different appliance, needs an updated authorization.
What the Program Actually Pays For
Approved treatment is paid in full. No copays, no deductibles, no annual benefit cap for children aged 0 through 20.1Department of Health Care Policy and Financing. Health First Colorado Children’s Dental Benefits Summary A private course of orthodontic treatment typically runs $3,000 to $10,000, so qualifying saves families real money.
Only what’s medically necessary and approved is covered. If your child wants clear or ceramic brackets instead of standard metal ones, the upgrade cost is on you. The same goes for anything a provider recommends outside the approved plan.
Retention care is covered too. Retainers keep teeth from shifting back once the braces come off, and lost or broken ones are nearly inevitable over a child’s growth. Health First Colorado reimburses providers separately for significant retainer repairs and full replacements, though a replacement needs its own prior authorization. Minor chairside fixes done at a scheduled appointment are treated as part of the original work.4DentaQuest. Criteria for Orthodontics – Colorado Health First
If Treatment Will Run Past Age 21
Plan around this one. If your child’s orthodontic treatment extends past their 21st birthday, Health First Colorado stops paying. The member becomes responsible for the remaining cost if they want to continue.4DentaQuest. Criteria for Orthodontics – Colorado Health First Stopping mid-treatment can undo the progress already made, so if your child is 18 or 19 when starting, talk frankly with the orthodontist about whether the full timeline fits within the coverage window.
If Your Request Is Denied
A denial isn’t always the end of it. The most common reason is that the HLD Index score fell below 26. Ask the orthodontist to review the measurements before you file anything formal. A legitimate measurement may have been understated, or a qualifying condition may not have been properly documented. A corrected resubmission sometimes succeeds where the first try failed.
If the denial stands, you have 60 days from the date on your Notice of Action to request a state fair hearing.6Health First Colorado. Appeals The hearing is a formal proceeding before a judge at the Office of Administrative Courts, and you can request one by mail, phone, fax, email, or through the OAC’s e-filing system. Your request needs to include your name, mailing address, phone number, Health First Colorado member ID, a description of the decision you’re appealing, and your reasons for disagreeing with it; attaching the denial letter helps.7Office of Administrative Courts. Filing an Appeal – Public Benefits The 60-day deadline is firm, so file before trying to resolve things informally.
What Isn’t Covered
Adults are out. Health First Colorado’s adult dental benefit lists orthodontia as “not a covered benefit” for members aged 21 and over, regardless of how severe the condition is.8Department of Health Care Policy and Financing. Health First Colorado Adult Dental Benefits Summary The adult benefit does cover exams, cleanings, fillings, extractions, root canals, crowns, and dentures with no annual cap, but braces are excluded. Adults with severe malocclusion generally have to look elsewhere, like dental schools offering reduced-cost treatment, orthodontist payment plans, or community health centers.
Child Health Plan Plus (CHP+) doesn’t cover braces either. CHP+ serves children in households earning up to 260% of the federal poverty level and includes dental benefits for exams, cleanings, fillings, and extractions, but orthodontic braces aren’t on the list.9Department of Health Care Policy and Financing. Child Health Plan Plus (CHP+) Dental Care CHP+ dental benefits are also capped at $1,000 per calendar year, which wouldn’t cover a multi-year case even if the benefit existed. If your child’s condition is severe enough to meet the HLD threshold and your household income drops into the Health First Colorado range, switching to Medicaid is the path to coverage.