HD45 - The Commonwealth's Policy of Medicaid Eligibility for Orthodontic Care


Executive Summary:
The General Assembly passed House Joint Resolution 476 (HJR 476), requesting a study be made by the Secretary of Health and Human Resources regarding Medicaid eligibility for orthodontic care. The Department of Medical Assistance Services (DMAS) Division of Client Services prepared this study, with assistance and expertise from providers and other payers, as well as literature reviews on the topic. Benefits and cost calculations were taken from Medicaid claims data.

A lack of consensus exists in the dental provider community regarding the reliability of the current criteria utilized in Virginia Medicaid policy for determination of orthodontic care eligibility. The mandate for orthodontic coverage is found in federal regulations related to Early and Periodic and Screening, Diagnostic and Treatment (EPSDT) benefits for individuals who have not reached their twenty-first birthday. Virginia has exercised its prerogative under EPSDT to set criteria for coverage. The criteria used in Virginia consist of a modified version of the Salzmann Index. The modification denies credit for esthetic anomalies and requires a 20-point score to certify a patient for orthodontic care.

Assumptions were made in the prologue to HJR 476 which dispute the use of Salzmann Index criteria as a valid evaluation tool; however, a search of the literature shows no well-documented superior process. In point of fact, the American Association of Orthodontists (AAO) is currently funding two studies to compare the tools currently available for measuring need for orthodontic care. The results of these studies are due in mid-1996.

In interviews with a number of "expert" orthodontists (as defined by referral from professional organizations, etc.), DMAS staff was unable to determine a consensus of opinion on the value of the current model.

Some tentative recommendations were put forth for making the review process contain "quantitative and qualitative criteria, and that such criteria be heavily weighted toward functional need" as recommended in HJR 476. In light of the AAO contracts with two researchers to evaluate measurement criteria available currently, the prudent course would seem to be postponing any decisions temporarily. If, or when, a recommendation is agreed upon by the professional associations, changes in current policy may be made.

Should the Secretary determine a need for immediate action on this matter, the above-mentioned recommendations may be used in the deliberations of this issue.