Objective Examine state-level Medicaid reimbursement rates after Medicaid expansion for Phase I and II orthodontia relevant to patients with cleft lip and palate. Design Cross-sectional study of publicly available 2024 state Medicaid reimbursement rates associated with Phase I and II orthodontia. One-Way ANOVA and independent t-tests compared regional and Medicaid expansion groups. Setting National sample of Medicaid reimbursement fee schedules. Patients Fifty US states, including DC, utilizing fee-for-service reimbursement for Medicaid enrollees. Main Outcome Measure (s) Reimbursement Rates for CPT Code D8020 (Phase I: Limited Orthodontia, Transitional Dentition) and D8080 (Phase II: Comprehensive Orthodontia, Adolescent Dentition) were compared between regions and by Medicaid expansion status. Results Ten states did not adopt Medicaid Expansion (19. 6%: AL, FL, GA, KS, MS, SC, TN, TX, WI, and WY). Coverage of Phase I care was low overall (58. 5% of expanded and 55. 6% of non-expanded states), with average reimbursement of 1080. 13. More states offered Phase II coverage (87. 8% of expanded and 77. 8% of non-expanded states). Phase II reimbursement was higher in expansion states (2596. 73 ± 2252. 59 vs non-expansion: 1266. 78 ± 314. 19; P =. 001). The South trended toward higher reimbursement for Phase II (3224. 95; P =. 093), followed by the West (2902. 88 ± 1327. 40 vs 1413. 26-1699. 10). Conclusions Provider reimbursement influences access to orthodontia. Although Medicaid expansion aims to improve access for low-income families, gaps in orthodontic coverage persist. Despite higher Phase II reimbursement in Southern and expansion states, inadequate Phase I coverage and low reimbursement schedules limit provider participation, leaving low-income patients with clefts at risk for delayed or absent orthodontia and thus suboptimal outcomes.
McCall et al. (Fri,) studied this question.