South Carolina Medicaid does cover braces, but only for children under 21 whose orthodontic problem is severe enough to qualify as medically necessary. Healthy Connections, the state’s Medicaid program, uses a scoring tool called the Handicapping Labio-Lingual Deviation (HLD) index to draw that line. A child generally needs an HLD score of 30 or higher, or one of several automatically qualifying conditions, before coverage kicks in. Cosmetic straightening does not qualify.
Adults 21 and older are not covered. South Carolina’s orthodontic policy lists orthodontics for this age group 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
How South Carolina Decides Medical Necessity
An orthodontist completes the HLD Assessment form, evaluating specific features of the child’s bite and dental alignment, assigning point values, and totaling them. A child qualifies for comprehensive orthodontic treatment 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 form with supporting evidence.
- An automatic qualifying condition that bypasses scoring because it inherently impairs oral function.
Conditions That Automatically Qualify
These 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.
- Deep impinging overbite, where the lower front teeth are damaging the soft tissue of the palate.
- Anterior crossbite with tissue destruction, where individual front teeth cross over in a way that is destroying surrounding soft tissue.
- Severe overjet: a horizontal gap greater than 9 mm with lips that cannot close properly, or a reverse overjet greater than 3.5 mm.
- Severe traumatic deviations from injury.
- Surgical malocclusion requiring orthognathic (jaw) surgery to correct the bite.
If the child’s condition doesn’t match any of these and the HLD score falls below 30, Medicaid will not cover treatment. Most denials happen here, so accurate HLD scoring matters.
Age Limits and the “Finish Before 21” Rule
The child must be enrolled in South Carolina Medicaid. Partners for Healthy Children covers children up to age 19 in families with income 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 Orthodontic coverage under EPSDT extends to Medicaid enrollees under 21.
The catch for older teenagers: the treatment plan must show that 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 runs past the cutoff.1South Carolina Department of Health and Human Services. Orthodontic Services Processes and Policies
Getting Prior Authorization
Even when a child clearly qualifies, Medicaid won’t pay without prior authorization. The orthodontist submits the request to DentaQuest, the company that administers dental benefits for Healthy Connections. The package includes the completed HLD Assessment form, diagnostic images, a written narrative of medical necessity, all anticipated procedure codes for the full course of treatment, and the EPSDT field marked on the prior authorization form.1South Carolina Department of Health and Human Services. Orthodontic Services Processes and Policies
Only one prior authorization is issued per case, whether the treatment is comprehensive or limited, regardless of how many appointments the child needs. 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
An approved authorization covers the full course of orthodontic treatment, including periodic 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 closes, replacement costs fall to the family.
One boundary to know: South Carolina’s orthodontic policy does not specifically authorize clear aligner therapy such as Invisalign. Medicaid programs generally cover traditional metal braces. If your child’s orthodontist recommends aligners, ask upfront whether Medicaid will cover them, because approval is unlikely.
If Your Prior Authorization Is Denied
A denial notice from DentaQuest or SCDHHS triggers the right to appeal. The appeal must be filed within 30 days of the denial notice; missing that window can make the denial final.5South Carolina Department of Health and Human Services. Appeals
Appeals go to the SCDHHS Office of Appeals and Hearings and can be submitted online or by mail. Explain why you disagree with the denial and include documentation that strengthens the case for medical necessity. A more detailed narrative from the orthodontist, updated imaging, or a second opinion can make the difference. Filing an appeal is a request for an in-person hearing before a hearing officer, and families can bring a representative, whether an attorney, a friend, or a family member.5South Carolina Department of Health and Human Services. Appeals
If Medicaid Doesn’t Cover Your Child’s Braces
Families whose children don’t meet the medical necessity threshold still have options, but out-of-pocket costs are real. Traditional metal braces typically run between $3,500 and $7,000 nationally without insurance, depending on case complexity and location. Many orthodontists offer payment plans, and some dental schools provide reduced-cost treatment. To confirm benefit details or find a participating Medicaid dentist for an initial evaluation, South Carolina families can reach DentaQuest at (888) 307-6552.