Impact of Medicaid Expansion on State-Level Medicaid Reimbursement for Orthodontia in Patients With Cleft Lip and Palate: A Cost Analysis

Abstract

Objective

Examine state-level Medicaid reimbursement rates after Medicaid expansion for Phase I and II orthodontia relevant to patients with cleft lip and palate.

Design

Cross-sectional study of publicly available 2024 state Medicaid reimbursement rates associated with Phase I and II orthodontia. One-Way ANOVA and independent t-tests compared regional and Medicaid expansion groups.

Setting

National sample of Medicaid reimbursement fee schedules.

Patients

Fifty US states, including DC, utilizing fee-for-service reimbursement for Medicaid enrollees.

Main Outcome Measure(s)

Reimbursement Rates for CPT Code D8020 (Phase I: Limited Orthodontia, Transitional Dentition) and D8080 (Phase II: Comprehensive Orthodontia, Adolescent Dentition) were compared between regions and by Medicaid expansion status.

Results

Ten states did not adopt Medicaid Expansion (19.6%: AL, FL, GA, KS, MS, SC, TN, TX, WI, and WY). Coverage of Phase I care was low overall (58.5% of expanded and 55.6% of non-expanded states), with average reimbursement of $1080.13. More states offered Phase II coverage (87.8% of expanded and 77.8% of non-expanded states). Phase II reimbursement was higher in expansion states ($2596.73 ± $2252.59 vs non-expansion: $1266.78 ± $314.19; P = .001). The South trended toward higher reimbursement for Phase II ($3224.95; P = .093), followed by the West ($2902.88 ± 1327.40 vs $1413.26-$1699.10).

Conclusions

Provider reimbursement influences access to orthodontia. Although Medicaid expansion aims to improve access for low-income families, gaps in orthodontic coverage persist. Despite higher Phase II reimbursement in Southern and expansion states, inadequate Phase I coverage and low reimbursement schedules limit provider participation, leaving low-income patients with clefts at risk for delayed or absent orthodontia and thus suboptimal outcomes.