Does Arkansas's cleft-palate and craniofacial insurance coverage law apply to Medicaid, and how much dental work does it require an insurer to cover?
Subject
Whether Medicaid counts as a "health benefit plan" under Arkansas's cleft-palate / craniofacial insurance coverage statute (A.C.A. § 23-79-1501), and whether the statute's "dental care" mandate covers comprehensive dental work or only the dental care tied to the patient's craniofacial condition.
Plain-English summary
Representative Carlton Wing asked the AG to interpret two pieces of Arkansas's cleft-palate and craniofacial coverage law: Act 373 of 2015 and Act 955 of 2021, codified at A.C.A. §§ 23-79-1501 to -1502. The law tells "health benefit plans" issued in Arkansas that they must cover reconstructive surgery and related medical care, including dental care, for patients with a craniofacial anomaly when an approved cleft-craniofacial team finds the work medically necessary. Two questions: does Medicaid count as one of those "health benefit plans," and does the dental-care mandate cover the patient's entire mouth or only the part affected by the cleft.
On Medicaid, the AG declined to give a yes-or-no answer because Medicaid is not one program. Traditional Arkansas Medicaid is fee-for-service: the state pays providers directly, no private "plan" sits in between, so it probably falls outside the § 23-79-1501 definition. The Affordable Care Act expansion population, by contrast, is enrolled in private Marketplace insurance plans whose premiums Medicaid pays. Those private plans look more like the "individual, blanket, or group plan, policy, or contract for healthcare services issued or delivered in this state" that the statute targets. PASSE (Provider-Led Arkansas Shared Savings Entity) programs, which use private risk-based provider organizations to take capitated payments for certain Medicaid populations, also have features that look like a health benefit plan. The AG pointed out that other parts of the Arkansas Code expressly include or exclude Medicaid from their own "health benefit plan" definitions, while § 23-79-1501 simply doesn't say. Whether any specific Medicaid arrangement is in or out turns on a three-part test in the statute itself: the program must be a plan, policy, or contract for healthcare services; it must be issued or delivered in Arkansas; and it must be issued by a healthcare insurer, HMO, hospital medical service corporation, or self-insured governmental or church plan.
On dental coverage, the AG took the narrower reading. The statute requires coverage of "reconstructive surgery and related medical care," and "medical care" is defined to include dental care. But the trigger for coverage is the cleft-craniofacial team's medical-necessity determination, and the necessity has to be tied to "a functional impairment that results from the craniofacial anomaly." So the dental-care duty rises and falls with what the team approves as medically necessary to fix the functional impairment from the craniofacial condition. It is not a blanket comprehensive dental benefit. The AG added the standard caveat that his office does not make factual findings, so he could not say whether comprehensive dental work would qualify in any specific case; that is up to the cleft-craniofacial team to decide patient by patient.
What this means for you
Parents of a child with cleft palate or another craniofacial anomaly
If your child has private insurance issued in Arkansas, the carrier owes coverage for the surgery, the related medical care, and the dental work that an approved cleft-craniofacial team certifies as medically necessary to address the functional impairment. Insist on the team's written medical-necessity determination tying the requested dental work to the functional impairment from the craniofacial condition, because that is the document the carrier has to honor. If your child is on traditional Medicaid, this AG opinion suggests the cleft-palate insurance mandate may not apply directly, but Medicaid has its own Early and Periodic Screening, Diagnostic and Treatment (EPSDT) coverage rules for children that often reach the same care. If your child is in a PASSE or in a Marketplace plan paid for by Medicaid expansion, the mandate is more likely to apply because those arrangements look more like the "health benefit plans" the statute targets.
If a request is denied, the question to ask the carrier is which prong of the § 23-79-1501 test they think excludes them. If they argue Medicaid is exempt, push back with the AG's three-part test and the structure of your specific program; "Medicaid" is not a magic word that exempts every program from the statute.
Cleft-craniofacial teams and treating clinicians
You are the gatekeeper for this benefit. The statute makes coverage turn on your medical-necessity determination, and the AG specifically said his office cannot do that determination for you. Document the functional impairment (speech, swallowing, breathing, occlusion, dental arch development), document the link between the proposed dental work and the impairment, and write the medical-necessity letter so a claims reviewer can see the chain. If you think a comprehensive course of dental care is medically necessary to address the functional impairment, say so explicitly and explain why. The AG opinion contemplates that this can happen.
Health insurance compliance officers and managed care plans
For each plan or program you operate, walk through the § 23-79-1501(2)(A) elements. If your product is a plan, policy, or contract for healthcare services, issued in Arkansas, by a healthcare insurer, HMO, hospital medical service corporation, or self-insured governmental or church plan, you have a § 23-79-1502 duty to cover cleft and craniofacial reconstructive surgery and related medical care, including dental care that the cleft-craniofacial team certifies as medically necessary for the functional impairment. The fact that Medicaid funds your premiums or capitates your payments does not by itself exempt you. Update claim-decision logic and prior-authorization criteria so reviewers do not deny dental claims that come with a cleft-craniofacial team's medical-necessity letter.
PASSE provider organizations
PASSEs receive capitated payments from the state and operate as risk-bearing entities that look much like managed care organizations. The AG cited A.C.A. § 23-79-1905(c)(1) for the proposition that a health benefit plan can be offered by a PASSE risk-based provider organization. Treat PASSE coverage decisions for cleft and craniofacial care under the § 23-79-1501 to -1502 framework: cover what the cleft-craniofacial team certifies.
Traditional fee-for-service Medicaid administrators
The AG opinion suggests fee-for-service Medicaid is unlikely to be a § 23-79-1501 "health benefit plan" because the state pays providers directly, with no plan-like intermediary. That does not mean traditional Medicaid is free of cleft and craniofacial coverage obligations: federal Medicaid law and EPSDT have their own rules. But the specific Arkansas insurance-mandate framework in § 23-79-1502 is more likely to bite the insured-product side of Medicaid (Marketplace expansion enrollees, PASSE) than the fee-for-service side.
State legislators
The AG flagged a structural inconsistency in the Arkansas Code: some "health benefit plan" definitions explicitly include Medicaid, others explicitly exclude it, and § 23-79-1501 is silent. If the legislature wants the cleft-palate mandate to reach all of Medicaid (or none of it, or only specific Medicaid programs), the cleanest fix is to amend § 23-79-1501(2) to say so. Until then, coverage applies program by program based on a structural test, which is workable but creates litigation risk.
Common questions
Does my child's traditional Medicaid card mean they cannot get cleft-palate coverage?
No. The AG opinion is about whether one specific Arkansas insurance-coverage statute applies; it is not about whether Medicaid as a whole covers cleft-palate care. Medicaid has separate federal and state rules, including EPSDT for children, that often require coverage of medically necessary cleft and craniofacial services. If your child's claim is denied, ask the program to identify which authority governs and what the appeal path is.
Are PASSE plans subject to the cleft-palate mandate?
Most likely yes. The AG cited the statute that defines a PASSE risk-based provider organization as a possible offeror of a "health benefit plan," and PASSE products are issued in Arkansas and pay for healthcare services, which lines up with the § 23-79-1501 elements. A PASSE that denies cleft and craniofacial coverage solely on the theory that "Medicaid is not a health benefit plan" is on shaky ground.
Does this mean my child's plan has to cover braces, fillings, and routine cleanings?
Only if the cleft-craniofacial team certifies that those services are medically necessary to improve the functional impairment from the craniofacial anomaly. The AG took the narrow reading: the dental-care duty is tied to the craniofacial condition. Routine dental work that is not connected to the cleft or craniofacial condition is not covered by this mandate. (Other parts of your plan might still cover routine dental care; this statute is not the only source of coverage.)
What is an "approved cleft-craniofacial team"?
The statute references it without defining it in detail. In practice it is a multidisciplinary team (typically including plastic surgery, oral and maxillofacial surgery, ENT, speech-language pathology, orthodontics, and pediatric dentistry, often credentialed by the American Cleft Palate-Craniofacial Association). Plans should accept medical-necessity determinations from teams that meet recognized standards of approval; the statute makes the team's determination the gating event.
Can the AG tell me whether my plan has to cover a specific dental procedure?
No, and the AG was explicit about that. AG opinions interpret the law as applied to general fact patterns. They do not adjudicate individual claims or make medical-necessity determinations. Take the AG's framework, get the cleft-craniofacial team's medical-necessity letter, and submit the claim. If denied, the dispute moves to the plan's appeals process and ultimately to the courts or the Insurance Department.
Background and statutory framework
Act 373 of 2015 and Act 955 of 2021 amended Arkansas's insurance code to require health benefit plans to cover certain reconstructive and related care for craniofacial anomalies, codified at A.C.A. §§ 23-79-1501 to -1502.
The "health benefit plan" definition in § 23-79-1501(2)(A) reads: "an individual, blanket, or any group plan, policy, or contract for healthcare services issued or delivered in this state by a healthcare insurer, health maintenance organization, hospital medical service corporation, or self-insured governmental or church plan in this state." The statute provides nonexhaustive lists of what is included and excluded in subsections (2)(B) and (2)(C), and Medicaid is not on either list.
That silence is unusual within the Arkansas Code. Other "health benefit plan" definitions take a position. A.C.A. §§ 23-79-1601(2), -1801(1), -2202(2), -2401(3), -2702(5), and -2801(1) expressly include Medicaid. A.C.A. § 23-79-2002(1)(B) expressly excludes it. A.C.A. § 4-88-117(b)–(c) lists health benefit plans and Medicaid as separate categories. So the legislature knows how to address Medicaid when it wants to. In § 23-79-1501, it didn't.
The AG read that silence as inviting a structural test. Medicaid is not a single thing; it is a collection of programs that operate differently. A.C.A. § 20-77-107 establishes traditional fee-for-service Medicaid, where the state pays providers directly. A.C.A. §§ 20-77-2701 to -2709 set up the PASSE program, which uses private risk-based provider organizations to take capitated payments and deliver services to certain Medicaid beneficiaries. The Affordable Care Act's Medicaid expansion in Arkansas channels many enrollees through private Marketplace plans rather than traditional Medicaid; only the premiums are paid with Medicaid funds. Each of those structures has different answers to the § 23-79-1501 three-part test.
The AG also pointed to A.C.A. § 17-105-125(b) and § 17-80-404(b)(3) for the proposition that Arkansas law contemplates Medicaid sometimes operating through "health benefit plans," and to § 23-79-1905(c)(1) for the recognition that PASSE risk-based provider organizations may offer health benefit plans.
The dental-coverage analysis turns on § 23-79-1502. Subsection (a)(1) requires coverage of "reconstructive surgery and related medical care" for a person diagnosed with a craniofacial anomaly, but only if "an approved cleft-craniofacial team" determines the surgery and treatment are "medically necessary to improve a functional impairment that results from the craniofacial anomaly." Subsection (b) defines "medical care" to include dental care. The AG read those provisions together: the dental-care duty is tied to the cleft-craniofacial team's medical-necessity determination, and that determination has to be linked to the functional impairment from the craniofacial anomaly. Comprehensive dental care is possible but only if the team certifies it on those terms.
The AG closed with the standard non-factfinding disclaimer, citing prior opinions Ops. 2024-092, 2017-088, and 2007-308 for the rule that the AG does not make case-specific factual determinations.
Citations
- A.C.A. § 23-79-1501 (definitions for cleft and craniofacial coverage statute, including "health benefit plan")
- A.C.A. § 23-79-1501(2)(A) (the operative three-element definition)
- A.C.A. § 23-79-1501(2)(B)–(C) (nonexhaustive inclusions and exclusions; Medicaid not listed)
- A.C.A. §§ 23-79-1601(2), -1801(1), -2202(2), -2401(3), -2702(5), -2801(1) (other Arkansas health benefit plan definitions that include Medicaid)
- A.C.A. § 23-79-2002(1)(B) (Arkansas health benefit plan definition that excludes Medicaid)
- A.C.A. § 4-88-117(b)–(c) (separately listing health benefit plans and Medicaid)
- A.C.A. § 20-77-107 (traditional Arkansas Medicaid program)
- A.C.A. §§ 20-77-2701 to -2709 (PASSE program for risk-based provider organizations)
- A.C.A. § 17-105-125(b) (referencing health benefit plans provided by Arkansas Medicaid)
- A.C.A. § 17-80-404(b)(3) (same)
- A.C.A. § 23-79-1905(c)(1) (PASSE risk-based provider organizations may offer health benefit plans)
- A.C.A. § 23-79-1502(a)(1) (mandate to cover reconstructive surgery and related medical care, conditioned on cleft-craniofacial team determination)
- A.C.A. § 23-79-1502(b) ("medical care" includes dental care)
- Act 373 of 2015 and Act 955 of 2021 (the underlying enactments)
- Ark. Att'y Gen. Ops. 2024-092, 2017-088, 2007-308 (AG does not make factual determinations)
Source
Original opinion text
Opinion No. 2025-014
April 29, 2025
The Honorable Carlton Wing
State Representative
2513 McCain Boulevard, Suite 208
North Little Rock, Arkansas 72116
Dear Representative Wing:
I am writing in response to your request for my opinion about Act 373 of 2015 and Act 955 of 2021. You ask:
- Under A.C.A. § 23-79-1501, is Medicaid considered a "health benefit plan"?
Brief response: Sometimes. Medicaid comprises multiple programs, each of which operates differently. Whether any specific Medicaid program in Arkansas fits the definition of "health benefit plan" in A.C.A. § 23-79-1501 will depend on how that program operates.
- Under A.C.A. § 23-79-1501, does "dental care" mean comprehensive dental care for the patient's entire oral cavity or just the part of the mouth affected by the cleft palate or craniofacial problem?
Brief response: The latter. The law requires coverage for dental care only if an approved cleft-craniofacial team determines it is "medically necessary to improve a functional impairment that results from the craniofacial anomaly." Thus, a health benefit plan must cover comprehensive dental care only if the cleft-craniofacial team makes that determination.
DISCUSSION
Question 1: Under A.C.A. § 23-79-1501, is Medicaid considered a "health benefit plan"?
A.C.A. § 23-79-1501 defines "health benefit plan" as "an individual, blanket, or any group plan, policy, or contract for healthcare services issued or delivered in this state by a healthcare insurer, health maintenance organization, hospital medical service corporation, or self-insured governmental or church plan in this state." Although the statute includes a nonexhaustive list of plans that are explicitly included and excluded from the term "health benefit plan," Medicaid is not listed. This contrasts with other sections in the Arkansas Code that define "health benefit plan" to either explicitly include or exclude Medicaid.
Medicaid comprises multiple programs, each of which operates differently. For example, traditional Medicaid in Arkansas is "almost entirely a fee-for-service system," where "the state pays health care providers directly for each service provided to the Medicaid enrollee." But after the Affordable Care Act's Medicaid expansion, many Medicaid beneficiaries "must enroll in private insurance plans offered through Arkansas's … Health Insurance Marketplace, instead of through traditional Medicaid." For these beneficiaries, only the individual's premiums are covered by Medicaid funds; the State does not directly pay providers for services.
Each Medicaid program's structure determines whether it is a "health benefit plan" in § 23-79-1501. Some Medicaid programs are likely "health benefit plans" in § 23-79-1501; some are likely not. A Medicaid program will be a "health benefit plan" if the program has the following three elements: (1) it is "an individual, blanket, or group plan, policy, or contract for healthcare services" (2) that is "issued or delivered in this state" (3) "by a healthcare insurer, health maintenance organization, hospital medical service corporation, or self-insured governmental or church plan in this state."
Question 2: Under A.C.A. § 23-79-1501, does "dental care" mean comprehensive dental care for the patient's entire oral cavity or just the part of the mouth affected by the cleft palate or craniofacial problem?
Health benefit plans, as defined in A.C.A. § 23-79-1501, must cover "reconstructive surgery and related medical care" for a person "who is diagnosed as having a craniofacial anomaly." But this duty only applies if an "approved cleft-craniofacial team" determines that "the surgery and treatment are medically necessary to improve a functional impairment that results from the craniofacial anomaly." "Medical care" is then defined to "include coverage for … dental care."
Thus, dental care is covered only if it is "related" to "reconstructive surgery" and is "medically necessary to improve a functional impairment that results from the craniofacial anomaly." The scope of "medically necessary" dental coverage is a fact-bound determination that must be made by an "approved cleft-craniofacial team."
It is possible that in some situations an approved cleft-craniofacial team will determine that comprehensive dental care is "medically necessary." But this Office is not a factfinder when issuing opinions, so I cannot opine whether comprehensive dental care will be medically necessary in any specific instance.
Deputy Attorney General Noah P. Watson prepared this opinion, which I hereby approve.
Sincerely,
TIM GRIFFIN
Attorney General