Does Medicaid Cover Braces in Ohio? Qualifying Rules and Appeals

Ohio Medicaid does cover braces, but only for members under 21 and only when the dental condition is severe enough to be considered medically necessary. Cosmetic cases are excluded. When a case is approved through prior authorization, the family pays nothing — the full cost of active treatment and retention is covered.¹ Adults 21 and older are not eligible for orthodontic coverage.

Who Qualifies for Covered Braces

Three conditions have to line up. The patient must be under 21. The malocclusion must be documented as having an adverse medical or psychosocial impact, not just a cosmetic one — Ohio refers to these as “extreme cases.”² And the member must not have already received comprehensive orthodontic treatment paid for by Medicaid, because braces are a once-per-lifetime benefit. A new request after a prior paid course may be authorized at $0, though the managed care plan still has to review the request on medical necessity grounds.³

There is no copay or cost-sharing when treatment is approved.¹

How Ohio Decides a Case Is Severe Enough

Severity is not left to the orthodontist’s judgment. Ohio uses a standardized scoring form, ODM 03630, revised in September 2025 and required for all new prior authorization requests starting January 1, 2026. The form was developed jointly by the Ohio Dental Association, the Ohio Department of Medicaid, and the state’s Medicaid managed care organizations.⁴ A case qualifies one of two ways.

Automatic Qualifiers

Seven conditions trigger automatic approval when documented with the required evidence:⁵

Severe overjet greater than 9.0 mm.
Severe reverse overjet greater than 3.5 mm.
Anterior crossbite involving two or more anterior teeth, with photographic evidence of gingival recession.
Impinging overbite with photo evidence of palatal soft tissue laceration or clinical attachment loss.
Anterior impactions where eruption is blocked compared with the opposite tooth, root formation is advanced, and extraction is not indicated.
Craniofacial anomalies affecting the jaws or teeth from a congenital or developmental disorder, trauma, or pathology.
Severe maxillary anterior crowding greater than 8.0 mm.

Point-Based Qualification

If no automatic condition applies, the orthodontist scores the patient across measurable conditions and the total has to reach 22 points. Each condition carries a weight: reverse overjet is multiplied by 5, open bite by 4, ectopic teeth by 3. Posterior crossbite adds a flat 4 points. Documented psychosocial injury or speech impairment each add 10 points. Some conditions can’t be combined — overjet and reverse overjet, or overbite and open bite, are mutually exclusive.⁶

Individual managed care plans may layer their own clinical criteria onto the review, but the ODM 03630 is the statewide standard.

What the Orthodontist Has to Submit

Treatment cannot start without prior authorization from the child’s managed care plan. The orthodontist’s submission must include six items:⁷

Lateral and frontal photographs taken with lips together.
A cephalometric film with tracing, lips together.
A complete series of intraoral images.
At least one diagnostic model.
A treatment plan with projected length and cost.
The completed ODM 03630 form (Rev. 9/2025 for submissions from January 2026 onward).

If the plan denies the comprehensive treatment request, it may still pay for the diagnostic records that were produced for the submission.⁷

What’s Covered Once Approved

Approved treatment includes the initial placement visit, periodic active treatment visits, retention, and certain pre-orthodontic appliances:

D8080 covers comprehensive orthodontic treatment, including the placement visit and the first quarter of active treatment.⁸
D8670 covers up to seven additional calendar quarters of periodic visits, for a maximum of eight quarters of active treatment total — roughly two years.⁸
D8680 covers retention, including removal of appliances and construction and placement of retainers. It is limited to two per lifetime and requires authorization.⁹
D8210 and D8220 cover pre-orthodontic appliances such as expanders when medically necessary.³

Comprehensive orthodontic treatment is defined to include fixed and removable appliances as well as functional and orthopedic appliances.¹⁰ Ohio Medicaid policy documents don’t name clear aligners such as Invisalign specifically, but removable appliances fall within the covered definition and would be subject to the same medical necessity and prior authorization rules. Treatment beyond the eight-quarter cap is not paid for unless the provider submits extraordinary supporting documentation.¹¹

The EPSDT Backstop for Borderline Cases

If a child’s case doesn’t clear the standard scoring threshold, there is still a path. Federal law requires Medicaid to provide all medically necessary services to members under 21 through the Early and Periodic Screening, Diagnostic, and Treatment benefit, known in Ohio as Healthchek. The managed care plan has to cover a service a provider documents as medically necessary even if it isn’t on the standard fee schedule.¹²

For orthodontics, this means interceptive codes D8050 and D8060, which are not routinely on the fee schedule, can be approved through EPSDT with the right documentation.³ It also means a case that falls short of the ODM 03630 point count may still be considered when the record shows a documented medical, speech, respiratory, or psychosocial condition.¹⁰

What To Do If the Plan Denies the Request

A denial can be appealed, and the process has two levels.

File an internal appeal with the managed care plan within 60 days of the mailing date on the denial notice. The plan has 15 calendar days to decide. If the child’s health is at risk, request an expedited appeal, which must be resolved within 72 hours.¹³

If the plan upholds its denial, request a state hearing through the ODJFS Bureau of State Hearings. That request has to be filed within 90 to 120 days of the plan’s decision. To keep an existing authorization in place during the appeal, file within 15 days of the denial notice and before the current authorization expires.¹³

State hearings can be requested by phone at 866-635-3748 (option 1), online, by email at bsh@jfs.ohio.gov, by fax at 614-728-9574, or by mail to the ODJFS Bureau of State Hearings in Columbus. Disability Rights Ohio can help families navigate the process at 800-282-9181.¹³

Finding an Orthodontist Who Accepts Medicaid

Approval is one hurdle. Finding a provider is another, particularly outside metropolitan areas. Historically about 20% of Ohio dentists participated in Medicaid, compared with a national rate of 42%, and more than 30 Ohio counties don’t have enough dentists to meet basic community needs.¹⁴¹⁵ Participation has been rising since Ohio raised dental reimbursement rates by an average of 93% in January 2024 — the first increase in more than 20 years — and by mid-2025 the share of Ohio Dental Association members treating Medicaid patients had climbed from 18% to 31%.¹⁶¹⁷

To search for an in-network orthodontist, use the InsureKidsNow.gov Dentist Locator, select Ohio and the child’s dental plan, and filter by the “Orthodontics and Dentofacial Orthopedics” specialty.¹⁸ The Ohio Medicaid Consumer Hotline at 800-324-8680 can also help identify providers.¹⁹

Alternatives If Medicaid Won’t Cover Braces

If the case doesn’t clear the severity threshold, or the patient is 21 or older and so not eligible at all, a few options exist in Ohio:

Smiles Change Lives, a national nonprofit, provides braces to children ages 7 to 18 with moderate to severe orthodontic needs whose families meet income guidelines. The total family cost is a $30 application fee and a $650 treatment fee, with participating orthodontists donating their time.²⁰
Dental school clinics at Case Western Reserve University and The Ohio State University offer care from supervised student dentists, often at reduced cost.²¹
Community health centers across Ohio serve uninsured and underinsured patients, though availability varies by region.²¹

1
American Academy of Pediatric Dentistry. Ohio Medicaid Covered Services
2
Ohio Medicaid. Ohio Medicaid Managed Care Health Plan Comparison 2026
3
Ohio Department of Medicaid. Dental FAQ
4
Ohio Department of Medicaid. Medicaid Advisory Letter No. 689
5
DentaQuest. Ohio Form 03630 Scoring Guide
6
Ohio Department of Medicaid. Revised Form ODM 03630 Scoring Criteria
7
Molina Healthcare. Utilization Review Criteria – Orthodontic Services
8
Ohio Register. Ohio Department of Medicaid Public Hearing Notice
9
UnitedHealthcare Dental. Ohio Medicaid Dental Quick Reference Guide
10
UnitedHealthcare Dental. Medically Necessary Orthodontic Treatment
11
Molina Healthcare. Utilization Review Criteria – Orthodontic Services
12
Disability Rights Ohio. Medicaid EPSDT
13
Disability Rights Ohio. Medicaid Appeals Overview
14
National Library of Medicine. Dental Care Access for Medicaid-Enrolled Children in Ohio
15
The Ohio Newsroom. Ohio Doesn’t Have Enough Dentists
16
Oral Health Ohio. State Budget Update 2024-2025 Biennium
17
Ohio Dental Association. ODA Survey Shows Positive Impact of Medicaid Reimbursement Increases
18
InsureKidsNow.gov. Find a Dentist
19
Ohio Medicaid. Next Generation Medicaid FAQ
20
FindHelp.org. Smiles Change Lives – Orthodontic Treatment
21
Ohio Dental Association. Access to Care