May 2019 Volume LIV Number 3


Massachusetts Medical Plans Provide Dental and Orthodontic Coverage for Cleft Palate Patients in 2013

May 2013 Volume XLVIX Number 3

Massachusetts recently became the 20th state to require cleft lip and cleft palate health insurance coverage. Chapter 234 applies to all health plans sold in Massachusetts issued or renewed on or after Jan. 1, 2013, that provide coverage for hospital and surgical expenses.


The new law requires health plans sold in Massachusetts to cover treatment for cleft palate and cleft lip for insured members under the age of 18. Covered treatment must include medical, dental, oral, and facial surgery; surgical management and follow-up care by oral and plastic surgeons; orthodontic treatment and management; preventive and restorative dentistry to ensure good health and adequate dental structures for orthodontic treatment or prosthetic management therapy; speech therapy; audiology; and nutrition services, if such services are prescribed by the treating physician or surgeon who certifies that the services are medically necessary and consequent to the treatment of the cleft lip, cleft palate, or both.


Carriers may apply deductibles, coinsurance, copayments, or out-of-pocket limits to their coverage for cleft lip and cleft palate treatment. Blue Cross Blue Shield of Massachusetts notified providers last fall that it already provides coverage for many cleft lip and cleft palate services and will update their health plans to include coverage for the necessary dental and orthodontic services to treat these conditions.


According to a bulletin issued by the Massachusetts Consumer Affairs and Business Regulation on Dec. 31, 2012, Chapter 234 only applies to medical policies that provide coverage for hospital and surgical expenses. It does not apply to standalone dental plans. However, as it is possible that the dental and orthodontic services may be covered by both a health plan offering hospital and surgical expense coverage and a stand-alone dental plan, a health plan or a stand-alone dental plan may elect to coordinate benefits. In such an instance, the order of benefit determination for determining primary and secondary payers will apply as defined by Massachusetts COB rules (211 CMR 38.00).