medicaid dental expansion - marc gull
Topics in this Blog
What was the old rule?
What were the side effects of this old rule?
What procedures are now covered by Medicaid?
Why did the rule change?
What was the old rule?
Medicaid is a federal program that is managed by the states, so it is different in every state. Several states including New York did not cover dental health care. Legally, New York was still required to cover medically necessary dental care. The list of what was medically necessary for dental care was very limited. For years, under New York Medicaid coverage rules, the State prioritized procedures that pulled infected teeth rather than saving infected teeth. For instance, if you had a tooth infection and were presented with the option to do a root canal to preserve an infected tooth or remove the infected tooth, Medicaid would only cover the later procedure.
Under the old rule, root canals and crowns on back teeth were only covered if a diseased tooth was essential to anchoring a denture or if removing the tooth was medically inadvisable. Dental implants were not covered at all by Medicaid. The old rule denied coverage for many procedures if the person requesting the procedure still had four upper and four lower matching back teeth. The State considered the presence of these specific eight teeth to be “adequate for functional purposes”, even though the average adult has thirty-two teeth.
What were the side effects of this old rule?
Pulling teeth in situations where the tooth can otherwise be saved can have many negative side effects. Once you have had a tooth pulled, your teeth begin shifting. This can lead to situations where further dental surgery may be necessary to repair the damage caused by these shifts. Medicaid would not cover these procedures but would only cover further removals of teeth. This created an unfortunate cycle where a person, who could not afford dental healthcare, was required to have their teeth pulled, which leads to health complications that require more teeth to be removed.
The prior rules that encouraged pulling teeth ignored the effects such procedure had on other aspects of the Medicaid recipient’s life. Aside from the daily difficulties eating and frequent pain there are serious psychological concerns that were ignored by the State. Dental health is an important part of societal standards. Tens of thousands of New Yorkers affected by this policy struggled with self-image issues and heightened depression due to having teeth pulled rather than the State covering the costs of their implants. The psychological harms of the daily struggles of body dysmorphia are serious and often ignored. Many of the victims expressed severe depression and an inability to maintain social relationships on account of the shame and stigma of having few remaining teeth. Dental healthcare is something we often take for granted but for these patients the lack of such healthcare has created permanent psychological damage that could have been entirely avoided by New York state.
Why did the rule change?
The Legal Aid Society sued the New York State Department of Health on behalf of recipients of Medicaid that were denied dental coverage for certain procedures that were not considered medically necessary. In Ciaramella v. Bassett, the Legal Aid Society alleged that the current restrictions on dental care in New York violated the Americans with Disabilities Act, the Rehabilitation Act, and the requirements of the Medicaid Act. On May 1, 2023, the Legal Aid Society announced a settlement agreement with the Department of Health and announced changes in the rules regarding dental coverage as part of the settlement.
What procedures are now covered by Medicaid?
The New York Department of Health will now include crown and root canal coverage and favor procedures that save teeth. Medicaid recipients will be able to receive dental cover in situations where extraction of the tooth is prevented by a medical condition, when the tooth is needed to secure another tooth, when a molar is needed to maintain a balanced and functional bite, and when a person has eight or more back teeth in contact.
The Department of Health will no longer automatically deny any claim for crown lengthening and dental implants. These procedures will now be considered medically necessary. Replacement dentures will now also be considered medically necessary.
What can I do if I have more questions?
The Center for Elder Law & Justice is available to help. New Yorkers can call us at (716) 853-3087 or use the form at the bottom of this page. In addition, our free legal advice helpline can provide answers to brief legal questions to residents of New York State who are 55 or older. Call at 1-844-481-0973 between 9am and 11am to reach an attorney directly or call and leave a message. The helpline can also be contacted via e-mail at helpline@elderjusiceny.org.
Eligibility guidelines in this post are subject to change at any time. This blog post is intended as general information only and should not be considered legal advice. You should consult with an attorney about your specific circumstances to learn more about your eligibility and options.