TDMR received the following from a Texas Medicaid dentist who wishes to tell his story about his history with the HLD scoring system and the current state of Medicaid for orthodontia. He asked to remain anonymous.
When I began working with the Medicaid program about 22 years ago, National Heritage Insurance Company (NHIC) was employed by HHSC to administer it for the dentists in Texas. Since orthodontists do not use the HLD evaluation in private practice, I found it new to me. Most citizens want straight teeth that occlude properly. Any area that is out of alignment is generally not acceptable. The American Association of Orthodontists has never considered anything less and always promoted proper occlusion to avoid areas susceptible to decay or periodontal problems.
I found difficulties in scoring the HLD difficult at first. There was not a lot of detailed information as to how to score it. I found, at first, that I received back my models, photos, x-rays and diagnostic workup with a note saying that my HLD score was less than 26 points. I also learned that, if I sent in 10 cases that would not qualify, only one would be receive payment for my workup costs. So, obviously, I needed help to know more how to score it and not spend a lot of extra money and time.
I immediately, contacted the dental director for assistance. Through his help, I learned. Turn downs were eliminated and I did not have to endure the unhappiness or irate mother that felt like it was my fault the child did not receive braces. I found that I could better evaluate a patient according to the government’s idea of orthodontic needs and not those of the AAO or the school which I attended.
When TMHP took over the management of the orthodontic program, the cases were easily transferred over to them from NHIC and treatment progressed without any interruption.. The only real difference I found was that TMHP required the orthodontist to list everything he would use in treatment because, if he found that during treatment he needed another special appliance to handle a particular problem, TMHP would not approve it. That was never a problem with NHIC.
Since I had learned how to, when I would see patient for an initial exam, determine if a patient had at least 26 points, I could tell a mother or father that his child would not qualify right then. They were never happy about that and would want me to send in the records anyway. I told them I could not bear that cost on a wishful hope.
When HHSC took the overall program away from TMHP and gave the patients to Delta Dental, DentaQuest and MCNA, transfer of patients was less than ideal, as it was with NHIC. Approval for all cases under treatment had to be resubmitted for continued care and was quite costly to the doctor and caused delays in treatment care for the patient in order to receive the transfer approval.
When the HLD scoring system was eliminated and the new system was added, I sent in a young black man’s case. He had an overjet of 14 mm, Class II skeletal pattern and his lower front teeth were biting literally into the upper palate. If there was ever a patient that needed orthodontic treatment, he did. The case was disapproved as not Medically Necessary. I knew then that there was no longer a Medicaid program for braces!