Pediatric Insurance Coverage Variation of Orthognathic Surgery and Orthodontic Treatment for Congenital Craniofacial Abnormalities

Abstract

Introduction: Orthognathic surgery and associated orthodontic treatment are necessary parts of care for children who have congenital craniofacial deformities. Inconsistencies in insurance coverage across the U.S. have led to serious barriers to care for many families. In an effort to describe common patterns of coverage, we report craniofacial coverage criteria for both medical and dental insurances. Methods: In this study, we analyzed medical policies of the top 50 market share insurance providers, as well as all dental policies available in the U.S., for a total of 776 policies. Included in this analysis are Medicaid and Children’s Health Insurance Program (CHIP). Results: A total of 94.1% of both private medical and dental policies provide up-front limited coverage of congenital-related treatments, along with 98.0% of Medicaid plans covering oral surgery for cleft palate. Almost all states (n = 47) offered at least one private medical plan that covered orthognathic surgery for congenital and craniofacial anomalies, while n = 3 states (Colorado, Ohio, West Virginia) did not offer any. Coverage for oral surgery and orthodontic treatment by private dental and standalone dental plans were consistent, with 80.9% (n = 518) plans offering (52 ± 14)% in-network coverage of costs for oral surgery and 55.6% (n = 356) offering a similar (49 ± 12)% out-of-network coverage. Forty-six Medicaid and 44 CHIP programs offered coverage of “oral surgery for cleft palate.” Of these plans, 8.8% (n = 9) covered oral surgery as a medical benefit and 2.9% (n = 3) required that the surgery be “medically necessary.” Fifty Medicaid and 48 CHIP plans offered coverage for orthodontia. Conclusion: Many systemic barriers remain in the way of consistent access to affordable care in the United States. Coverage for patients with congenital anomalies remains highly variable and greater efforts are needed to ensure consistent, comprehensive coverage.