THE VARIANCE BETWEEN ELIGIBILITY AND FUNDING FOR MEDICAID PATIENTS SEEKING ORTHODONTIC TREATMENT IN PENNSYLVANIA

Abstract

Objectives: Medicaid Insurance Provider funding decisions often differ from the orthodontic clinician, assessed by malocclusion indices used for approvals. This study analyzed differences between clinician and insurance, insurance providers, and time of year for funding approval of orthodontic treatment. Since many American orthodontic graduate programs utilize Medicaid access to care as their predominant source, our sample evaluated Temple’s University Orthodontic cohort, between January 1st, 2018 and Dec 31st, 2019. Methods: The sample included 1,576 individuals, with 926 insured by Company 2 or Company 3 and the remaining 207 insured by either Company 1, Company 4, Company 5, or Company 6. Malocclusion severity evaluation had an inter-examiner reliability ≥90%, using the Salzmann Evaluation Index, with a score of ≥25 determining treatment need. These scores along with intra and extra oral photographs, a cephalogram and panorex, and an intra oral scan were sent to the Insurance Provider, an employee of the insurance provider received the records submitted and made a funding decision. Results: Company 3 displayed the highest similarity to the orthodontic clinician’s assessment, agreeing 69.7% of the time. Company 2 and Company 4 showed the lowest similarity at 39.8% and 33.3% agreement respectively. Company 2 and Company 3 were significantly different from each other in the way they determined eligibility for funding with a P-value of <0.000. The time of year was significant, p-value <0.01, only for Company 3, with the highest agreement similarity in May at 73.2% and the lowest in November at 30.3%. Conclusions: Company 2 funds a significantly lower percentage of individuals submitted with a SEI score of ≥25 than all other Providers, excluding Company 4. These findings suggest that Company 2 is evaluating individuals significantly different from orthodontic clinicians, raising potential access to care concerns. The time of year was significant only for Company 3, although no overall trend was observed.