Defining medically necessary orthodontic care: A prerequisite for any health policy

Objectives:

 

Orthodontic coverage by public and private insurers is often limited by what is considered “medically necessary orthodontic care” (MNOC). This definition varies between private third party payers as well as between state insurance plans. This confusing and non-standardized system has left many children who need orthodontic treatment without insurance coverage for care. The objective of this paper is to review the existing definitions of MNOC and examine its redefinition in light of the Affordable Care Act.

Methods:

 

The authors reviewed current criteria and indices used to define medically necessary orthodontic care by leading state and private dental plans. The newest definition of MNOC, provided by the American Association of Orthodontics, is discussed as it relates to the Affordable Care Act. Recent activities to assess evidence to support MNOC care are reviewed.

Results:

 

The authors found inconsistency between and across states with regard to the definition of MNOC. Different private and government dental plans use different indices to determine medically necessary orthodontic qualification. This lack of uniformity leaves a gap in the insurance coverage for orthodontic care for many children who need this treatment.

 

Conclusions:

 

The current system to determine orthodontic eligibility falls short in many areas. The development of a uniform definition of MNOC which applies across states and dental plans is needed to capture those individuals who are in need of care. The development of a standardized process for all states and carriers is essential. The two-tiered policy structure as explored by the AAO is a step in the right direction.