The Burden of Braces in Cleft Care

Abstract

Introduction:

Many states, including ours, mandate coverage of orthodontic treatment as part of cleft care. Despite these mandates, barriers consistently arise for patients leading to lack of coverage, delays in care, and increased financial burden. This study aims to characterize the experience and challenges to obtaining coverage for braces as part cleft care for pediatric patients at our institution.

Methods:

An 18-item REDCap survey was distributed to parents of patients who had been seen in our craniofacial orthodontic clinic for braces from 2019 to 2024. The survey was distributed in English and Spanish based on primary language indicated in the patient’s chart. The survey addressed insurance provider status, the claim process, preauthorization requirement, percentage of coverage by medical and dental insurance, out-of-pocket cost after insurance coverage, and a free response for parents to share any additional experiences in obtaining coverage. Standard statistical analysis was performed.

Results:

Forty-one complete responses were received, with a response rate of 15.6%. 43.9% of respondents filed a claim with their medical insurance carrier. The claim process duration varied from minimal time to 6 months to 2 years maximum. Among those who did not file, 34.8% cited uncertainty as to whether insurance would cover treatment. Preauthorization was required for 50% of respondents, resulting in treatment delays until approval in 35.9% of survey participants. Medical insurance covered an average of 37.9% of costs, dental insurance covered 35.2%, leaving a median out-of-pocket expense of $2580.75 after coverage from either provider.

Conclusions:

Despite mandated coverage, families face significant barriers in securing insurance reimbursement for orthodontia. Additional education, advocacy, and policy enforcement are needed to improve access and compliance with state mandates.