Cleft Palate Foundation

A Good Question: “Will my dental insurance cover braces?”

A Good Question: “Will my dental insurance cover braces?”

The short answer is “No.” But your medical insurance probably will.

When we think of braces, what comes to mind? Middle-school? An overbite? Charming-but-crooked teeth?

For many kids with clefts, the use of orthodontia–braces–is an inevitable part of the long-term treatment plan, but not for the usual reasons we think of.

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Laurena 2014 CPF College Scholarship Recipient, shows off her smile and the sparkle of braces.

When indicated, orthodontic treatment prepares a patient for alveolar bone grafting of the cleft maxilla, for correcting malocclusions and for preparation of jaw surgery. In summary, orthodontic care may include primary orthopedic treatment in infancy and can extend through adulthood. –Parameters For Evaluation and Treatment of Patients withCleft Lip/Palate or OtherCraniofacial Anomalies, p. 20.

Okay, so that’s a mouth full. In other words, for kids with clefts, braces are a familiar tool used for what are probably unfamiliar purposes. And this is the challenge for families: When the treatment plan says it’s time for braces, insurance companies may see the claim as typical orthodontia–braces to help straighten teeth–when in the case of a cleft care treatment plan, it is a necessary part of care without which the remainder of treatment can’t move forward.

As you prepare for braces and the costs associated with them, keep in mind these general tips:

1) Orthodontia for cleft care should NOT be filed with dental insurance. Use dental insurance for routine cleaning and other dental care, but NOT for braces.

2) Orthodontia for cleft care SHOULD be filed with medical/health insurance.

3) Your orthodontist or surgeon should document medical necessity for the medical/health insurance claim.

4) Many orthodontists and surgeons may include their standard paperwork which often features a diagram of the mouth/teeth. Even without reading the details of the claim and documentation of medical necessity, a claim reviewer may deny that claim based on that diagram alone.

Is your family working with Medicaid? In many cases and in many states Medicaid will do a fine job of facilitating orthodontic care within the treatment plan. The bigger challenge is often finding a cleft-specializing orthodontist who also accepts Medicaid.

Whether you are working with private insurance, Medicaid or other resource, your cleft palate treatment team should be your go-to experts for filing insurance claims and communicating with insurance companies about this critical stage of care. An experienced treatment team will have worked through this process many, many times. Allow the team’s experience to help you learn the ropes.

What tips can you share with parents working with insurance for orthodontia?

11 Responses

  1. kathie
    We have had three sets of braces and the orthodontist' s office filed the claim, they are part of the local cleft palate team. Insurance was denied all three times, all different companies, the last one saying he was is out of network and they don't cover out of network.
    Reply
  2. julie durand
    In Minnesota there is a state statute that requires medical insurance to cover orthodontia for cleft palate children, however companies that are self-insured are not bound by the statute due to ERISA guidelines. We just ended a one-year appeal process with our employer (self-insured) but they will not budge. In the past, our cleft nurse coordinator said many self-insured companies would bend their rules because it was "the right thing to do" and orthodontia is considered a "standard level of care" for cleft palate but they are not willing to pay anything. But in the last year they are seeing many, many more insurance rejections for cleft and craniofacial coverage. We are livid about it and considering talking to our state senators about why this loophole exists.
    Reply
    • Lisa
      Julie, thank you for sharing your experiences with insurance coverage for braces and cleft care. Your nurse coordinator's point about orthodontia and cleft care being a "standard level of care" is a point that should be underscored when communicating with any insurance company, administrator, state insurance commmissioner's office or state legislators. In many--if not all--cases, including a copy of Parameters for Evaluation and Treatment of Patients with Cleft and other Craniofacial Anomalies with appeals and correspondence is a critical step in documenting the standard of care for clefts and educating decision makers about the issue. You may download a PDF of the document from the CPF website or request a complimentary printed copy at admin@cleftline.org.
      Reply
  3. Carmen
    I have two children. One with cleft lip and palate and the other cleft palate. My oldest being 20, is at the point where she is ready for implants and I am having the hardest time navigating the insurance system. Needless to say, we have exhausted our dental/orthodontia coverage long ago. I got a quote from one oral surgeon at a major dental school (18K plus just for the screws) but was then told that they only bill dental insurance and not medical insurance. I have a secondary medical insurance which when researching evidence of coverage I found a statement saying they cover implants due to congenital deformity such as cleft palate. My problem number one is: How do I get the service done if no oral surgeons bill medical insurance (medical codes not dental codes, blah blah)? My second problem is with it being the second coverage, I have to get a denial letter from the primary insurance first. Any suggestions/help would be appreciated.
    Reply
    • Lisa
      Carmen, thank you for sharing your experiences and questions. There are no straightforward answers. We do want to gather more information so that we can help figure out some leads and options for your family going forward. Please connect with us via email at lisa.gist.walker@cleftline.org. I look forward to working with you.
      Reply
  4. Jeannette Petrie Smith
    My 11 year old daughter was born with cleft lip and palate. She has had 2 surgeries and her first set of braces, partially paid for by medical insurance and partially out of pocket. We are entering the next stage of care which will be another expense. I am not happy with the team caring for my daughter and would like to work with another provider. I feel I should have a right to do this, but I am afraid this will pose a problem with the insurance. Can she even see a regular community orthodonist at this point or are we stuck with the same team?
    Reply
    • Lisa
      Hi Jeannette, Thank you for sharing your experiences and asking a great question. While we always hope that the family-team relationship is a positive and productive one, for any number of reasons a family may need to change teams for ongoing care. Assuming that your new team is experienced with managing insurance claims and willing to support you should problems arise, changing teams should not be an issue for insurance coverage. So, NO, you should never feel as if you are stuck with a team that isn't a good fit for you and your family. If you need assistance locating a new team, please drop us a line at info@cleftline.org or lisa.gist.walker@cleftline.org. Jeannette, it IS important that your new team include an orthodontist who specializes in cleft care. Most general, community orthodontists--that is, those who do not specialize in cleft and craniofacial care--will not treat a patient who has a cleft or other cranofacial birth difference but will refer to an orthodontist who specializes in that area of care. And that's as it should be. Orthodontic care for a mouth that has a cleft is a very unique, specialized area of expertise, not just for improved outcomes but to prevent damage to the cleft care and repair that has already been completed. Best of luck Jeannette, and always, let us know how we can help. LGW
      Reply
  5. Banan
    Hi, thank you for all your effort. I have a question. my sister who is 18 now was born with a cleft lip, palate and nose. currently we are trying to get her a dental bridge as she is not a good candidate for implants. i saw two providers who estimated that the bridge will cost more than 8000$ :' ( she has medicaid, and I was wondering if there is anyway that you can suggest for getting the insurance cover the cost or at least part of it, or if there is any dental insurance that we can get who will help us cover the cost thank you very much
    Reply
    • Lisa
      Hello, Great question and so very timely as Medicaid benefits may change or cease entirely beyond the age of 18. We want to underscore the value of your sister consulting with a cleft palate treatment team for her ongoing care. There are many great reasons for this but the most significant at this point is that a cleft palate treatment team is the most direct route and access to cleft-specialists such as prosthodontists and oral-maxilofacial surgeons, the most likely specialists to design your sister's bridge and preparation for it. Many cleft palate treatment teams, usually affiliated with public institutions like universities, will almost always include these hard-to-find specialists who also accept Medicaid. That's sort of the brief overview. Drop us a line at info@cleftline.org or lisa.gist.walker@cleftline.org and we'll help identify a local team or teams and their best contacts for Medicaid-friendly care for your sister. I do want to emphasize that finding coverage for care before through age 18, or sometimes, through age 21, can be a challenge but we usually have success. Finding coverage for care in the adult years is an enormous challenge and far less successful. We encourage you and your sister to aggressively search for care while she is still Medicaid eligible. Once a course of care has begun, Medicaid almost always approves its completion, even if the patient ages out of Medicaid coverage mid-treatment. Drop us a line, let us know in which state your sister lives, and we'll help identify a team from there.
      Reply
      • Banan
        Hi lisa I sent you an email, i was wondering if you got it?
        Reply
  6. Laura
    Hello! I'm looking for some help. I have a 13 year old daughter who was born with a unilateral incomplete cleft lip. It's now braces time. I've already had an extra tooth extracted two years ago in hopes that the "better" tooth would move over. Her teeth need to be fixed. Should we attempt to put this through as medical insurance? We are in Pennsylvania and personally I don't think any state should have a "law" which allows or denies. Cleft children inevitably need braces bottom line and covering for this treatment should be a no brainer. I'm not sure what our treatment will entail, we're walking in with patient history, and films.
    Reply

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