Illinois Medicaid Orthodontic Scoring Tool Officially Updated

Following strong support and advocacy from ISDS, the State of Illinois has officially implemented an updated orthodontic scoring tool within the Medicaid program. This achievement stems from our successful work during the 2024 legislative session to secure $12 million in state funding to modernize the tool and improve access to medically necessary orthodontic care.

Since the funding was secured, ISDS has worked closely with the Illinois Department of Healthcare and Family Services (DHFS) to update both the rules and scoring criteria. The result is a more responsive, transparent system for patients and providers alike.

What’s new: Automatic qualifiers now include the following conditions:

• Cleft palate or other craniofacial anomalies
• Deep impinging bite with signs of tissue damage, not just touching palate
• Anterior crossbite with gingival recession
• Severe traumatic deviation (i.e. accidents, tumors, etc)
• Overjet of 9mm or greater 
• Impacted teeth where eruption is impeded but extraction is not indicated. 

Effective Date: These updates apply retroactively to January 1, 2025.

New Provider Requirements: For any denied claims, the dental vendor must now supply the HLD scoring tool along with the specific score that led to the decision. This added transparency helps providers advocate more effectively for their patients.

The updated scoring tool can be found by clicking here.

DHFS also sent out a provider notice which can be found by clicking here.