Does Medicaid Cover Braces in Georgia? Qualifying Conditions and Costs

Georgia Medicaid does cover braces, but only when the orthodontic problem is severe enough to count as medically necessary. For nearly everyone that means a child or young adult under 21 whose condition either falls into one of nine auto-qualifying categories or scores at least 28 points on the Handicapping Labio-Lingual Deviation (HLD) Index.¹ Cosmetic cases, mild crowding, and most adult cases are not covered.

Who Georgia Medicaid Will Consider for Braces

Orthodontic coverage in Georgia is built on the federal Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit, which requires state Medicaid programs to provide comprehensive health services, including dental care, to eligible individuals under age 21.² That is the age window where braces are realistically available.

Your child’s Medicaid or PeachCare for Kids benefits are managed through one of three Care Management Organizations: Amerigroup, CareSource, or Peach State Health Plan.³ The CMO usually hands dental services off to a dental benefits manager such as DentaQuest, so the authorization paperwork for braces moves through that company rather than the CMO itself.

What Counts as Medically Necessary

Georgia does not approve braces because teeth look crooked or because an orthodontist recommends treatment. The state uses a structured scoring tool, the HLD Index, to measure how much a misalignment actually impairs health and function. The index assigns point values to features like overjet (how far upper teeth protrude past lower teeth), overbite depth, and teeth that have erupted significantly out of position. Overjet and overbite are measured in millimeters at one point each; ectopic teeth are scored at three points apiece, excluding wisdom teeth. When no auto-qualifying condition applies, the total must reach 28 points for the state to consider treatment medically necessary.¹

Minor spacing issues, slightly crooked teeth, and cosmetic concerns will not reach that threshold. The problem has to cause real difficulty with eating, speaking, or keeping the mouth healthy.

Nine Conditions That Qualify Automatically

Some conditions are severe enough to qualify without hitting the 28-point score. Georgia’s dental services manual lists nine:¹

Cleft lip or palate and other significant craniofacial anomalies.
Deep impinging overbite, where the majority of lower front teeth press into the roof of the mouth.
Severe traumatic deviation, such as accidental loss of the front portion of the upper jaw or significant oral pathology.
True anterior open bite, where the front teeth do not meet when the mouth is closed (not counting teeth that simply haven’t finished erupting).
Crossbite involving three or more teeth, including cases that are damaging gum tissue.
Impacted front teeth or canines that will not come in on their own without orthodontic or surgical help.
Overjet greater than 9 mm with lips that don’t close properly.
Reverse overjet greater than 3.5 mm, where the lower teeth protrude past the upper teeth.
Jaw misalignment requiring combined orthodontic and surgical correction.

If any of these apply, the orthodontist should flag the auto-qualifier directly on the HLD form rather than rely on the point total.

What Changes at Age 21

Once a Medicaid beneficiary turns 21, EPSDT no longer applies and the standard HLD point-score pathway closes.² Adults can still qualify if they have one of the nine auto-qualifying conditions above.¹

Georgia also expanded adult Medicaid dental benefits beginning in fiscal year 2025 to include preventive, diagnostic, restorative, and orthodontic surgery care.⁴ That opens coverage for jaw surgery and the orthodontic work tied to it. Routine braces for adult cosmetic concerns remain excluded.

Getting Approved: Referral, Documentation, and Timeline

Every orthodontic case needs prior authorization before treatment starts. The process begins with a referral from a general dentist to a Medicaid-enrolled orthodontist. The referring dentist coordinates the referral; the orthodontist then handles the prior authorization with the dental benefits manager.⁵ To find a Medicaid-enrolled orthodontist, use the provider directory on the Georgia Medicaid Management Information System (GAMMIS) portal⁶ or call the member services number on your CMO card.

The orthodontist’s submission package has to include:⁷

Panoramic or full-mouth X-rays showing the full jaw and all teeth, including unerupted ones.
A cephalometric film, which is a side-view X-ray used to measure how the jaw and skull relate.
Diagnostic-quality intraoral and facial photographs.
A completed HLD scoresheet showing every measurement and any auto-qualifying condition.
A written narrative of medical necessity from the orthodontist explaining the functional problems braces will correct.

The dental benefits manager has 30 days to decide once it has every required document.⁸ If the submission is missing anything, the clock resets when the orthodontist supplies the rest. You will get the decision in writing. An approval lets treatment begin; a denial will state the reason, typically a score below 28 or documentation that did not establish medical necessity.

What You’ll Pay

Members under 21 do not owe copayments for covered services in Georgia.⁹ Federal rules also require EPSDT services to be provided at no cost to eligible individuals under 18.² When prior authorization is approved, the full course of treatment, from placement through adjustments and removal, should be covered without out-of-pocket expense.

If your child’s condition does not meet the threshold and you decide to pay privately, a full course of orthodontic treatment nationally runs roughly $5,000 to $6,000, with wide variation by appliance type and case complexity.

If Your Request Is Denied

A denial can be appealed through a Fair Hearing, which you have 30 days from the denial notice to request.¹⁰ Hearings are conducted through the Office of State Administrative Hearings, and the denial letter will include filing instructions. You can submit a hearing request at any Division of Family and Children Services office, and the request is forwarded to OSAH for scheduling.¹¹

At the hearing you can show that the HLD score was calculated incorrectly, that an auto-qualifying condition was missed, or that relevant medical records were never considered. The state presents its reasoning, and an administrative law judge issues a written decision by mail.

Miss the 30-day deadline and you lose the right to appeal that denial. In many cases, asking the orthodontist to resubmit the prior authorization with better documentation is a faster route than a hearing, and the two paths are not mutually exclusive while the appeal window is still open.

1
Georgia Department of Community Health. Part II Policies and Procedures for Dental Services
2
eCFR. 42 CFR Part 441 Subpart B – Early and Periodic Screening, Diagnosis, and Treatment of Individuals Under Age 21
3
Georgia Department of Community Health. Medicaid Managed Care
4
Georgia Department of Audits and Accounts. Medicaid Dental
5
DentaQuest of Georgia, LLC. DentaQuest of Georgia Provider Quick Reference Guide
6
Georgia MMIS. Find a Provider
7
CareSource. Georgia Medicaid Dental Provider Manual
8
Georgia MMIS. The Basics of Medicaid Precertification
9
Peach State Health Plan. Co-Pays
10
Georgia Department of Human Services. Appendix B Hearings
11
Georgia Pathways to Coverage. Appeal an Eligibility Decision