.png){kind=logo}
Cleft lip or palate
Patients with cleft conditions typically have specialized orthodontic and surgical care plans coordinated with a craniofacial team. Medicaid coverage applies to the orthodontic phases.
Medicaid Braces Eligibility Guide
Does my child qualify for Medicaid braces in Delaware?
Delaware Medicaid covers medically necessary orthodontic treatment for children and teens under 21. This page explains exactly how qualification is determined - the HLD Index, auto-qualifying conditions, age and enrollment rules, and what happens after the free evaluation. The only way to know for certain whether your child qualifies is the free in-office evaluation, but reading this first will save you questions later.
Step 1 - Age and enrollment
Who is eligible to start the process.
Before the orthodontic exam matters, two administrative boxes must be checked. Most Medicaid families already meet both:
- Under 21 years old. Delaware's EPSDT benefit (Early and Periodic Screening, Diagnostic and Treatment) extends through the patient's 21st birthday. We see plenty of high-school seniors and 19- and 20-year-old patients who qualify.
- Enrolled in Delaware Medicaid. Active coverage through the Diamond State Health Plan (Highmark Health Options, AmeriHealth Caritas Delaware, or Delaware First Health) or the Delaware Healthy Children Program (CHIP). Bring your member ID card to the free evaluation.
If your child meets both, the clinical evaluation is the next gate. That is what the rest of this page covers.
Already know your plan?
Jump directly to the plan-specific overview:
- Highmark Health Options
- AmeriHealth Caritas Delaware
- Delaware First Health
- Delaware Healthy Children Program (CHIP) - covered like the DSHP plans
Step 2 - The HLD Index
The Handicapping Labio-Lingual Deviations Index, in plain English.
Delaware Medicaid uses the HLD Index - a standardized orthodontic scoring system used by many U.S. state Medicaid programs - to determine whether a case is medically necessary. Each measurement on the form is assigned points based on severity, and the points are added to produce a total score.
Delaware generally requires a total of 26 or higher to meet the medical-necessity threshold.
Measurements scored on the HLD form
An orthodontist evaluates your child and scores each of the following:
- Overjet (how far the upper front teeth project past the lower)
- Overbite (how far the upper front teeth cover the lower when biting together)
- Anterior crowding (how badly the front teeth are misaligned for space)
- Anterior open bite (vertical gap between upper and lower front teeth)
- Anterior crossbite (lower front teeth biting in front of upper)
- Posterior crossbite (lower back teeth biting outside upper)
- Ectopic eruption (teeth erupting in the wrong place)
- Missing permanent teeth
- Lingual labial spread (sideways spread of the front teeth)
How a case adds up
No single measurement is usually enough to hit the threshold on its own. Cases that qualify almost always have multiple findings - for example:
Example: An 11-year-old with a 7 mm overjet (significant), moderate anterior crowding, one ectopic canine, and a posterior crossbite. Each measurement adds points to the form, and the total comfortably exceeds the 26-point threshold.
The exact point weighting is determined by Delaware's HLD form rules at the time of evaluation. We score the form during your free Medicaid evaluation and tell you the total on the spot, along with which findings drove the score.
Step 3 - Auto-qualifying conditions
Some conditions qualify regardless of HLD point total.
Even if a child's HLD score does not reach 26, several specific conditions automatically meet the medical-necessity standard under Delaware Medicaid. If your child has any of these, the case generally qualifies.
Impacted maxillary anterior teeth
Upper front teeth (incisors and canines) that fail to erupt and require orthodontic guidance to bring them into the arch.
Severe deep overbite with palatal impingement
An overbite so deep that the lower front teeth contact the gum tissue of the upper palate, which can cause tissue damage over time.
Severe traumatic deviations
Malocclusion caused by accident or injury that has fundamentally shifted the bite or position of teeth.
Severe crossbite with functional impact
A crossbite causing the lower jaw to shift sideways when closing, affecting chewing function or facial development.
Other documented craniofacial conditions
Certain documented developmental or congenital conditions affecting the jaws and teeth qualify on a case-by-case basis. Our orthodontist evaluates these at the free evaluation.
Step 4 - The free evaluation
What happens at your child's free Medicaid evaluation at Stellar.
About 60 minutes at the office. No cost. No commitment.
1. Intake
We confirm your Medicaid plan and your child's date of birth from the member ID card. No PHI is collected by web form - intake happens in person.
2. Full orthodontic exam
The Stellar orthodontist examines the bite, alignment, and oral structures, and reviews any prior dental records you've brought.
3. Diagnostic records
Digital photos, x-rays as needed, and a digital iTero scan in place of goopy impressions. These become part of the pre-auth submission.
4. HLD scoring
Our orthodontist completes the Delaware HLD Index form using the exam findings and tells you the score before you leave. We also flag any auto-qualifying conditions.
5. The verdict
You leave the appointment knowing one of three things: clearly qualifies, clearly does not, or borderline (in which case we explain the submission strategy and likelihood).
6. Next steps
If your child qualifies, we begin the pre-authorization submission. If not, we discuss private-pay options and financing - no pressure, no obligation.
Step 5 - Pre-authorization
How Stellar submits your child's case to Medicaid.
Pre-authorization is the formal request to your managed-care plan to approve covered orthodontic treatment. The administrative work is the reason many families never end up using their Medicaid orthodontic benefit. Stellar handles the entire submission for you.
- Records package: diagnostic photos, panoramic and cephalometric x-rays, digital scans, and the completed HLD form - all uploaded electronically to the plan.
- Timeline: typically 2 to 4 weeks for a decision once the package is submitted.
- Decision delivery: the plan notifies both Stellar and the patient family of the determination. We call you as soon as we have the answer.
- If approved: we schedule the braces placement appointment promptly. Treatment begins. No member cost-share for the covered services.
- If denied: see the next section.
For the full submission and appeals workflow, see our Medicaid braces process guide.
Step 6 - If pre-auth is denied
You still have options.
Denials happen - sometimes because the score was borderline, sometimes because the case is genuinely cosmetic rather than medical. Stellar will not surprise you. We walk through the options:
- Written appeal to the managed-care plan, often with additional clinical documentation.
- Peer-to-peer review - a direct call between the Stellar orthodontist and the plan's dental consultant.
- Delaware Medicaid fair hearing through the state DMAP program for unresolved cases.
- Private-pay path with monthly financing if you'd still like to proceed with treatment.
We never start treatment without your written consent and clear understanding of cost.
Eligibility FAQ
Honest answers to the qualification questions families ask most.
How do I know if my child qualifies?
Schedule a free Medicaid orthodontic evaluation at any Stellar office. Our orthodontist completes a full exam, scores the HLD Index, and checks for auto-qualifying conditions. You learn whether your child qualifies before leaving the office.
What HLD score qualifies for Medicaid braces in Delaware?
Delaware Medicaid generally requires an HLD Index score of 26 or higher. Cases that score below 26 may still qualify if they have an auto-qualifying condition (cleft palate, impacted maxillary anterior teeth, severe deep overbite with palatal impingement, severe traumatic deviations, severe crossbite).
What is the HLD Index?
The Handicapping Labio-Lingual Deviations Index is a standardized scoring system Delaware Medicaid uses to evaluate orthodontic medical necessity. Specific measurements (overjet, overbite, anterior crowding, crossbites, missing teeth, open bite, ectopic eruption) are scored and added to produce a total. A score of 26+ generally meets the medical-necessity threshold.
What conditions auto-qualify?
Auto-qualifying conditions include cleft lip and palate, impacted maxillary anterior teeth, severe deep overbite with palatal impingement, severe traumatic deviations, and severe crossbite with functional impact. These qualify regardless of HLD point total.
What is the age limit?
Patient must be under 21 and enrolled in DSHP or CHIP. EPSDT coverage runs through age 20.
How long does pre-authorization take?
Typically 2 to 4 weeks once Stellar submits the complete records package electronically.
What happens if pre-auth is denied?
Stellar reviews the denial reason and walks you through the options - written appeal, peer-to-peer review with the plan's dental consultant, a Delaware fair hearing through DMAP, or a private-pay plan with monthly financing. We will never start treatment without explicit consent and a clear cost understanding.
Does my dentist need to refer my child?
Often no. Most Delaware Medicaid plans allow self-referral for orthodontic evaluation. Some plans appreciate (but do not require) a referral letter from a general dentist or pediatric dentist. Stellar can confirm your specific plan's requirements when you call.