Third-party Compliance With State-Mandated Orthodontic Coverage for Cleft Palate and Craniofacial Care in California: An Insurance Claim Thematic Analysis.

BACKGROUND

California Senate Bill 630 (SB630) enacted statutorily mandated health plan coverage for orthodontic care of patients with cleft palate and craniofacial anomalies in 2009, which was effective from July 1, 2010. In this qualitative analysis, third-party compliance with SB630 in a university-based cleft and craniofacial orthodontic program is evaluated.

METHODS

Privately insured patients that experienced a coverage delay or denial of orthodontic treatment for cleft lip and palate in the University of California, San Francisco Cleft and Craniofacial Orthodontic Program between July 1, 2010 and October 28, 2020 were identified. A thematic analysis of reasons for delay or denial was conducted.

RESULTS

Nearly three quarters of patients experienced coverage delay and/or denials. The most common reason given was that services were not covered.

CONCLUSIONS

Despite state-mandated coverage, inappropriate denials of orthodontic care for patients with cleft lip and palate by private insurers persist in California.