172. Disparities in Insurance Coverage of Cleft Lip and Palate: A Comparative Analysis of State Healthcare Policies and Legal Frameworks

PURPOSE: Nonsyndromic cleft lip with or without cleft palate (CL/P) is a prevalent congenital anomaly worldwide that poses significant health challenges. Today, the U.S. lacks a unified approach to CL/P coverage. METHODS: This paper explores the U.S. medical-legal framework surrounding CL/P, identified via the PubMed, Google Scholar, Lexis, and Westlaw databases. It examines the Affordable Care Act (ACA), the Health Insurance Portability and Accountability Act (HIPAA), and state-level variations in CL/P coverage. The paper conducts a case study on statutes pertaining to CL/P coverage across three states: Massachusetts, Indiana, and Illinois. RESULTS: Through this case study, potential coverage loopholes affecting equitable access to healthcare for individuals with CL/P are identified. Massachusetts’ policy is more detailed and comprehensive in its scope and implementation. Massachusetts’ policy, enacted in 2012, addresses a far broader range of treatments needed in CL/P, including medical, dental, oral and facial surgery, orthodontic treatment, speech therapy, audiology, and nutrition services - some of which may not be feasible to provide in the newborn phase. The Massachusetts policy also empowers treating physicians to determine the necessity of services, ensuring coverage if they certify them as medically necessary for the treatment of CL/P. On the contrary, the Indiana policy does not address coverage for children beyond the newborn phase or the necessity for additional support services. As a result, these services may not be readily available as the child progresses in age. Furthermore, Massachusetts explicitly includes oral and plastic surgeons in its coverage, recognizing the importance of both primary repair surgeries and revision procedures. While the Indiana policy may provide for this using much broader language, there is a question as to whether revision procedures outside the newborn period would be covered. By not providing a more comprehensive approach, Indiana may inadvertently restrict access to procedures that would improve patient outcomes and exacerbate the challenges faced by patients with CL/P in receiving comprehensive care. It could be argued that narrowing the scope of the provision to newborns further complicates the process of obtaining necessary treatments and excluding it would better assure patients’ ability to access the holistic care they require. CONCLUSION: The current state policies regarding CL/P treatment exhibit commendable intentions but lack the necessary clarity and specificity to ensure comprehensive coverage. Disparities in coverage exist between states like Massachusetts, which has detailed policies, and states like Indiana, which have limitations potentially leaving gaps in care access beyond infancy. Healthcare reform for CL/P coverage should address these disparities, guaranteeing holistic care for patients with CL/P, improving their quality of life, and minimizing disparities in access to necessary treatments. The findings underscore the need for legal reform to ensure equitable access for patients with CL/P across the U.S