South Carolina Medicaid does cover braces, but only for enrollees under 21 whose orthodontic problem is severe enough to count as medically necessary. Cosmetic straightening is not covered. The state uses a scoring tool called the Handicapping Labio-Lingual Deviation (HLD) index, and a child generally needs a score of 30 or higher, or one of several automatically qualifying conditions, before Healthy Connections will pay.
How a Child Qualifies
South Carolina turns the medical necessity question into a measurable score. An orthodontist evaluates specific features of the child’s bite and alignment, assigns point values on the HLD Assessment form, and totals them. A child qualifies for comprehensive orthodontic treatment under Medicaid in one of two ways:1South Carolina Department of Health and Human Services. Orthodontic Services Processes and Policies
- An HLD score of 30 or higher, documented on the HLD form with supporting evidence.
- An automatic qualifying condition that bypasses the scoring system entirely.
Conditions That Qualify Automatically
The following diagnoses qualify a child without needing to reach the 30-point threshold:2South Carolina Department of Health and Human Services. Handicapping Labio-Lingual Deviation Index HLD Assessment Form
- Craniofacial anomalies, including cleft lip or palate, Pierre-Robin sequence, hemifacial or craniofacial microsomia, Crouzon syndrome, Apert syndrome, Treacher-Collins syndrome, or condylar aplasia.
- A deep impinging overbite where the lower front teeth are damaging the soft tissue of the palate.
- Anterior crossbite where individual front teeth cross in a way that is destroying surrounding soft tissue.
- Severe overjet greater than 9 mm with lips that cannot close properly, or a reverse overjet greater than 3.5 mm.
- Severe traumatic deviations caused by injury.
- Surgical malocclusion requiring orthognathic (jaw) surgery to correct the bite.
If a child’s condition doesn’t match any of these and the HLD score falls below 30, Medicaid will not cover orthodontic treatment. Most denials happen at this line, so accurate HLD scoring and strong supporting documentation matter.
Age and Timing Rules
Orthodontic coverage under EPSDT applies to Medicaid enrollees under 21, but there is a timing catch families often miss: the treatment plan must show the orthodontic work will be completed before the child turns 21. If the child is 19 and the orthodontist estimates a 30-month course, Medicaid will likely deny coverage because the timeline extends past the cutoff.1South Carolina Department of Health and Human Services. Orthodontic Services Processes and Policies
For income eligibility, South Carolina’s Partners for Healthy Children program covers children up to age 19 in families at or below 213 percent of the federal poverty level, and infants under one may qualify at higher income levels.3South Carolina Department of Health and Human Services. Medicaid Eligibility Programs
South Carolina Medicaid does not cover orthodontic services for anyone 21 or older. The policy lists orthodontics for adults as “not a covered service,” including for individuals on intellectual disability or related disability waivers.1South Carolina Department of Health and Human Services. Orthodontic Services Processes and Policies
Prior Authorization Is Required
Even when a child clearly qualifies, Medicaid will not pay for braces without prior authorization. The orthodontist submits the request to DentaQuest, the company that administers dental benefits for Healthy Connections.1South Carolina Department of Health and Human Services. Orthodontic Services Processes and Policies The package must include:
- The completed HLD Assessment form
- Diagnostic images and supporting documentation
- A written narrative of medical necessity
- All procedure codes anticipated for the full course of treatment
- The EPSDT field marked on the prior authorization form
Only one prior authorization is issued per case for either comprehensive or limited orthodontic treatment, no matter how many appointments the child will need.1South Carolina Department of Health and Human Services. Orthodontic Services Processes and Policies While the request is pending, the provider cannot bill the family for the treatment.4South Carolina Department of Health and Human Services. Dental Services Provider Manual
What’s Covered Once Approved
Approved cases include the full course of treatment: periodic orthodontic visits, adjustments, and the retention phase after the braces come off. Medicaid covers one retention visit per case, which includes removing the braces, final adjustments, and placing retainers.
If a retainer is lost or broken, Medicaid allows one replacement per arch within 12 months of the retention visit.1South Carolina Department of Health and Human Services. Orthodontic Services Processes and Policies After that window, replacement costs fall to the family.
One boundary to flag: South Carolina’s orthodontic policy does not specifically authorize clear aligner therapy such as Invisalign. If your child’s orthodontist recommends aligners, confirm coverage before starting, because approval is unlikely.
If the Request Is Denied
A denial from DentaQuest or SCDHHS comes with a written notice explaining the reason, and that notice starts the clock on your right to appeal. South Carolina requires the appeal to be filed within 30 days of receiving the denial.5South Carolina Department of Health and Human Services. Appeals Miss that window and the denial can become final.
Appeals go to the SCDHHS Office of Appeals and Hearings and can be filed online or by mail. Explain why you disagree and include anything that strengthens the medical necessity case: a more detailed narrative from the orthodontist, updated imaging, or a second opinion. Filing an appeal is a request for an in-person hearing before a hearing officer, and you can bring a representative such as an attorney, friend, or family member.5South Carolina Department of Health and Human Services. Appeals