Health Insurance

Appropriate postnatal care is essential after any child’s birth, and that’s especially true if your baby was born with an orofacial cleft.

We’ve outlined the most common forms of treatment, including surgical repair and ongoing therapies, on our “Treating Cleft Lip & Palate” page, but we haven’t yet broached the subject of paying for these services, which are often more expensive than those that babies born without congenital defects require.

Health Insurance & Orofacial Cleft Coverage

To complicate the matter, many children born with orofacial clefts benefit from multiple forms of treatment that can be spaced out over time, extending even into the late teens. And there’s always the added difficulty of working with an interdisciplinary team of craniofacial specialists, rather than a single pediatrician.

All this can make handling insurance issues confusing and frustrating for the parents of children born with orofacial clefts.

But the most common problems that families run into involve getting certain types of treatment covered in the first place.

Will Insurance Cover My Child’s Treatments?

If your family currently has private health insurance, or is enrolled in a group plan, it’s likely that your policy will cover at least a portion of the necessary treatments for cleft lip and / or cleft palate.

If you haven’t done so already, contact your insurance company and request a copy of the document called “Evidence of Coverage.” You’ll have to read this very closely, especially the section that lists “Exclusions.” These are the types of treatment that your insurer is not required to pay for according to your policy’s contract.

“Cosmetic” Procedures & Dental Conditions

Your policy may exclude a lot of different treatments, but the two most common that create problems for families of children with orofacial clefts are:

  1. Exclusions that pertain to cosmetic procedures
  2. Exclusions that pertain to dental conditions

If you are denied for any reason, request a copy of the denial and read it carefully. Note their reasoning behind the denial and which portions of your Evidence of Coverage (EC) they reference to justify it. Now look through your EC and find out how long you have to appeal the decision.

“Cosmetic” Procedures: Appealing A Denial

Procedures that repair orofacial clefts are considered “cosmetic surgery,” and are usually performed by plastic surgeons. Despite the fact that these procedures are actually intended to improve your child’s basic quality of life, your insurance company may initially deny a claim for cleft lip or palate repairs.

In any appeal, your primary task is to prove that the procedure is not actually “cosmetic,” but medically necessary.

According to the American Medical Association (AMA), “cosmetic surgery” is “entirely focused on enhancing a patient’s appearance. Improving aesthetic appeal, symmetry, and proportion are the key goals.”

While your child’s procedure will most likely improve his or her appearance and self-confidence, those are not it’s “key goals.”

Instead, cleft lip or palate repair is more accurately considered “plastic” or “reconstructive” surgery. Here’s the AMA again on these types of surgery: plastic surgery is “dedicated to reconstruction of facial and body defects due to birth disorders, trauma, burns, and disease. Plastic surgery is intended to correct dysfunctional areas of the body and is reconstructive in nature.”

In your appeal, emphasize the fact that this surgery is not meant to improve normal bodily structures, but repair abnormal ones. Base your appeal on the idea that basic activities, ones that found any concept of quality of life, like speech, breathing and swallowing, can be painful and difficult for children with orofacial clefts. You are trying to show that these repairs are not “elective,” but necessary.

Dental Conditions: Appealing A Denial

Unfortunately, many of the specialists you will work with (like maxillofacial surgeons) submit standardized “dental” forms to insurance companies in support of claims. If your policy does not cover dental work, you may be denied out-of-hand.

As in the case of “cosmetic” procedures, your appeal will need to stress the medical necessity of the procedures. You can mention that no dental procedures exist to repair an orofacial cleft, and that the treatments your child will undergo are not actually “dental” in nature.

If you need sample letters or help with drafting an letter, please feel free to contact us by email at: rachel@cleftsmile.org or fill out the form on the side of this page.

State Laws That Require Orofacial Cleft Coverage

In 15 states, laws have been passed that require insurance companies to cover additional services that aren’t usually included in a basic policy.

California

Passed in 2009, this law requires “every health care service plan contract, except a specialized health care service plan contract” that is issued in California to cover “reconstructive surgery” necessary “to improve function” or “create a normal appearance, to the extent possible.”

Since July 1, 2010, the definition of “reconstructive surgery” has included “medically necessary dental or orthodontic services” integral to the repair of cleft palate, cleft lip and other craniofacial anomalies associated with cleft palate.

Connecticut

Connecticut’s Public Act No. 03-37 states that individual health insurance policies classified as either:

  • Basic hospital expense coverage
  • Basic medical-surgical expense coverage
  • Major medical expense coverage
  • Hospital or medical service plan contract
  • Hospital and medical coverage provided to subscribers of a health care center

must “provide coverage for medically necessary orthodontic processes and appliances for the treatment of craniofacial disorders for individuals eighteen years of age or younger.” This requirement is limited, though. In particular, the orthodontic treatments must be prescribed by “a craniofacial team recognized by the American Cleft Palate-Craniofacial Association.” You can find a craniofacial team certified by the ACPCA in your area here.

While Connecticut’s law covers orthodontic procedures and devices, it does not require insurers to handle expenses that result from “cosmetic surgery.”

Florida

Florida’s law goes further. According to Section 627.64193 of that state’s General Statutes:

“A health insurance policy that covers a child under the age of 18 must provide coverage for treatment of cleft lip and cleft palate for the child. The coverage must include medical, dental, speech therapy, audiology, and nutrition services.”

Indiana

Indiana’s Insurance statute requires that newly born children be extended the benefits to which their parents are entitled, “including the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities.”

This coverage must include, but need not be limited to, “benefits for inpatient or outpatient expenses arising from medical and dental treatment (including orthodontic and oral surgery treatment) involved in the management of birth defects known as cleft lip and cleft palate.”

You can find the law here by searching for “IC 27-8-5.6-2”

Louisiana

As of 2008, Louisiana’s insurance laws include Section §215.8, which requires that “any hospital, health, or medical expense insurance policy […] include coverage for the treatment and correction of cleft lip and cleft palate.”

By law, these benefits “shall include but not be limited to the following:

  1. Oral and facial surgery, surgical management, and follow-up care.
  2. Prosthetic treatment such as obturators, speech appliances, and feeding appliances.
  3. Orthodontic treatment and management.
  4. Preventive and restorative dentistry to insure good health and adequate dental structures for orthodontic treatment or prosthetic management or therapy.
  5. Speech-language evaluation and therapy.
  6. Audiological assessments and amplification devices.
  7. Otolaryngology treatment and management.
  8. Psychological assessment and counseling.
  9. Genetic assessment and counseling for patient and parents.”
Maryland

According to Maryland’s Insurance Statute, Section 15–818:

“each individual or group hospital or major medical insurance policy […] shall include benefits for inpatient or outpatient expenses arising from orthodontics, oral surgery, and otologic, audiological, and speech/language treatment involved in the management of the birth defect known as cleft lip or cleft palate or both.”

Minnesota

Minnesota’s Insurance Statute, Section 62A.042 mandates that individual accident and sickness insurance policies which provide for the coverage of more than one person must extend benefits to “newborn infants immediately from the moment of birth and therafter,” including “coverage for illness, injury, congenital malformation, or premature birth.”

This coverage includes: “benefits for inpatient or outpatient expenses arising from medical and dental treatment up to the limiting age for coverage of the dependent, including orthodontic and oral surgery treatment, involved in the management of birth defects known as cleft lip and cleft palate.”

New York

On April 1, 2013, New York State’s Senate amended existing insurance laws to include the requirement that:

“Every policy which provides medical, major medical, or similar comprehensive-type coverage shall include coverage for cleft lip and cleft palate. This shall include coverage not only for the treatment of the gross abnormalities of lip and palate but also for any condition or illness which is related to or developed as a result of cleft lip and/or palate. Coverage shall include, but not be limited to, expenses for the following:

  • Oral surgery of the lip, palate, jaw and related structures. This shall include bone grafts;
  • Facial surgery of the lip, palate, jaw, nose and related structures. This shall include bone grafts;
  • Prosthetic treatment and appliances and prosthodontia, including obturators, speech appliances, and feeding appliances;
  • Orthodontic treatment and appliances and orthodontia;
  • Preventive and restorative dentistry;
  • Otolaryngology treatment and management;
  • Audiological treatment and devices;
  • Speech/language treatment; and
  • Psychological counseling and genetic counseling.

Coverage shall include expenses for assessment, evaluation, treatment, management, and follow-up care. Coverage shall not be denied on the ground that it is for cosmetic purposes or is not a functional defect or impairment.”

North Carolina

Section 58-51-30 of North Carolina’s Insurance Statute requires that:

“every health benefit plan [that] extends coverage to a newborn child” shall include the same benefits “for congenital defects or anomalies as are provided for most sicknesses or illnesses suffered by minor children that are covered by the plans. Benefits for congenital defects or anomalies shall specifically include, but not be limited to, all necessary treatment and care needed by individuals born with cleft lip or cleft palate.”

South Carolina

South Carolina’s Insurance Statute contains Section 38-71-240, which states that:

“any individual or group accident and health policy which provides dependent coverage shall provide coverage for the medically necessary care and treatment of cleft lip and palate and any condition or illness which is related to or developed as a result of a cleft lip and palate.”

“Medically necessary care and treatment” includes, but is not limited to:

  • oral and facial surgery, surgical management, and follow-up care made necessary because of a cleft lip and palate;
  • prosthetic treatment such as obdurators, speech appliances, and feeding appliances;
  • medically necessary orthodontic treatment and management;
  • medically necessary prosthodontic treatment and management;
  • otolaryngology treatment and management;
  • audiological assessment, treatment, and management performed by or under the supervision of a licensed doctro or medicine, including surgically implanted amplification devices; and
  • medically necessary physical therapy assessment and treatment.”
Texas

According to Section 1367.151 of Texas’ Insurance laws, health benefit plans must extend coverage to children younger than 18 years of age for “reconstructive surgery for craniofacial abnormalities,” defined as “surgery to improve the function of, or attempt to create a normal appearance of, an abnormal structure caused by congenital defects, developmental deformities, trauma, tumors, infections, or disease.”

Vermont

Vermont’s Health Insurance Statute, Section 4089g states that:

“a health insurance plan shall provide coverage for diagnosis and medically necessary treatment, including surgical and nonsurgical procedures, for a musculoskeletal disorder that affects any bone or joint in the face, neck or head and is the result of accident, trauma, congenital defect, developmental defect, or pathology.”

Note that this section does not also “require coverage for dental services for the diagnosis or treatment of dental disorders or dental pathology primarily affecting the gums, teeth, or alveolar ridge.”

Virginia

According to Virginia’s Insurance Statute, Section 38.2-3411, individual and group accident and sickness insurance policies are required to cover children newly born to the insured, and must extend to “inpatient and outpatient dental, oral surgical, and orthodontic services that are medically necessary for the treatment of medically diagnosed cleft lip, cleft palate or ectodermal dysplasia.”

Wisconsin

In Wisconsin, every “surgical, medical, hospital, major medical or other health service coverage” policy “shall provide coverage for a newly born child of the insured from the moment of birth.”

This coverage must “consider congenital defects and birth abnormalities as an injury or sickness under the policy and shall cover functional repair or restoration of any body part when necessary to achieve normal body functioning, but shall not cover cosmetic surgery performed only to improve appearance.”

For the Statute’s full text, click here and refer to paragraph 5.

The descriptions of State Statute provided above are for informational purposes only, and may not represent the most current legal developments. Please visit official sources.