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New Oregon Medicaid Orthodontic Benefit Effective 1/1/2023

Updated: Dec 28, 2022

New Oregon Medicaid Orthodontic Benefit Effective 1/1/2023


What is changing for Oregon’s 465,000 kids on OHP?


Effective January 1, 2023, the Oregon Health Authority has agreed to cover handicapping malocclusion (HCM) as part of the benefits for youth under 21 years who are members of the Oregon Health Plan. This means that OHP members will now have access to braces where there were none before except where a cleft palate or severe cranial anomalies were involved.


What to Expect:


Although Oregon will use the California model of the HLD index with an HLD index of 26 or higher as a guide for the HCM criteria, our state’s population is perhaps more comparable with Washington’s, so it makes sense to prepare for the benefit by looking north for guidance. Washington has covered the orthodontic benefit for years and their experience will help us set the most realistic expectations. As an example, roughly 0.08% of Washington’s youth in their Medicaid program were approved for and started orthodontic treatment in 2010 (4). With Oregon’s 465,000 children on OHP, we can expect about 3750 kids approved for orthodontic treatment annually, statewide, by using the same ratio.


Opportunities for Orthodontists:


Besides a guaranteed income source through a variety of approved ADA billing codes, you may also have a strong voice in how the benefit is shaped as we move forward into 2024. The Oregon Health Authority has held many public meetings to align all the moving pieces in the best way possible, and your input will be strongly needed in the future.


OHP Patients who don’t qualify for the OHP benefit may convert to a fee-for-service (FFS) treatment with your practice, which could help increase your paying patient base. Additionally, you can bill OHP for preliminary orthodontic-related services, like an initial consultation, that some orthodontic offices offer for free as an incentive to acquire new FFS patients.


Moreover, if your practice is in an area characterized by a low-income population, this new covered benefit will help secure patients with guaranteed payment and no financial services or collections to deal with. Many of these benefits are relevant for general and pediatric dentists as well.


Perhaps you are in a place where you can look at this as an opportunity to give back to the community that has helped you build your business, in which case the true gratifications of serving the OHP population, as we do at ASK, are plentiful.



Relevant Links:


This initial briefing is from A Smile for Kids, and not from OHA. We have heard that several of the providers we partner with are unaware that this is coming, so we feel that you need to be informed and we would like to share as much as we can. This is your professional field, and Oregon’s kids need your help. To that end, ASK would like to turn you towards the facts that we know so far. Below you have access to the current parameters around the new benefit:


1. New List of Prioritized Services effective January 1, 2023 (See page 5, Guideline note 169)

2. DCO Contracts and Compliance Workgroup June 15, 2022 (See slide 4 for proposed rates)

3. FFS Decision Flow/Tree – Request for Orthodontia from Oregon Health Authority

4. Washington Orthodontic Stats for Youths (American Journal of Orthodontics, 2016)


What’s in it for A Smile for Kids:

With the state benefit covering the most severe needs for orthodontic treatment, ASK can focus on the kids in Oregon who don’t necessarily meet the State criteria, but still have a severe need for treatment and will benefit from the grade and volunteer requirement we have in place. This new benefit will allow us to stretch our resources and our supporters’ donations further, increasing health outcomes for Oregon’s communities.


What’s Next?

It’s no secret that the Medicaid benefit will need providers who are willing to jump in and serve patients who qualify. It’s also no secret that many oral health providers have lost resources from missed appointments these last few years of COVID-19. A Smile for Kids has managed compliance for orthodontic patients since 2004 – and we would love to continue to do that for the patients covered with this new state benefit. It’s just a matter of making all the moving pieces fit together, but we will keep you posted as we know more.


Feel free to reach out to ASK if you need help digesting the little information we know so far. We can also help you connect with OHA if you would like some direct contact information.


Sincerely,


Christian Moller-Andersen

cma@asmileforkids.org

Executive Director


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