New York Courts Rule that Five Million New Yorkers Will Get Restorative Dental Care. Really?

The Legal Aid Society successfully fought and won a class action lawsuit that challenged the New York State Department of Health’s restrictions for adult dental care. The lawsuit that was initiated in 2018 was finally settled on May 1, 2023, directing that Medicaid should provide restorative dental care including bridges, implants, root canals, and other medically necessary services for the more than eight million New Yorkers currently on the program.

The successful argument by the Legal Aid Society stated that since New York State covers “optional care” – the federal government’s term – such as dentistry, that this cannot be restricted to only select basic services. Until now, New York State rules for the state’s Medicaid program only allowed for pulling infected or abscessed teeth, not dental preservation, while also maintaining severe limits on denture and implant coverage. These policies left thousands of low-income New Yorkers facing the choice of suffering with dental pain, further medical complications, being toothless, barriers to employment and social isolation.

For the millions who have suffered the impacts of Medicaid’s denials of care, the ruling has the potential to improve health outcomes statewide. However, under current statewide reimbursement rates, health professionals are not incentivized to accept Medicaid patients. Medicaid claims are reimbursed to health professionals at much lower rates than other insurance plans. For example, per the 2023 NYS Medicaid Dental Policy and Procedure Code Manual and Updated Fee Schedule, dentists are reimbursed just $25 for a general cleaning for a Medicaid patient. Low reimbursement rates in the face of rising insurance costs, rising costs of supplies, and for new dentists the enormous student loan debt they must continue to pay, creates a system that is detrimental to both dental professionals and patients when seeking to provide dental care in low-income communities.

“The ruling begs the question of who is going to enforce it,” explained CCMP Operations Manager Elisabeth Stevens. “Many services now covered under the new Medicaid ruling still require prior authorization, including replacement of lost or damaged dentures and all implant-related services. The incentive is for the health insurance providers to provide as little care as possible, it is the same for the state Department of Health and Medicaid.”

CCMP is currently working on multiple advocacy cases for benefit recipients whose Medicaid HMOs are denying restorative care – months after the ruling. A CCMP benefit recipient who uses Medicaid for his healthcare told CCMP that while he was waiting three months for the next available appointment with his dentist to address a tooth that cracked in half, the pain got to be so bad that he used pliers and ripped the tooth out himself.

“Our volunteer advocates will demand accountability from the government and ultimately demand the right of all working people to have comprehensive healthcare,” stated CCMP Benefit Coordinator Simone Hardaway. “And as long as this ruling stands, we will seek to hold the state government accountable to provide the restorative dental care of which so many New Yorkers are in dire need.”

Medicaid compliance falls under the auspices of the Bureau of Compliance of the New York City Department of Health (DOH). Typically, Medicaid pays for a recipient’s care through a managed care organization (MCO) or health maintenance organization (HMO). It is these HMOs and MCOs that pay professionals for patients’ services. “Since the advent of managed care in the 1980s, CCMP has opposed HMO and MCO practices of ‘healthcare rationing,’” explained Advocacy Benefit Coordinator Tasluba Bushra. “This rationing is where managed care companies rank diagnoses and treatments by cost, then refuse coverage for anything more expensive than they’re willing to pay for – regardless of how medically necessary or effective that item may be.”

One of the most notable gaps in this ruling is that it does not apply to anyone under the age of 21. Under NY DOH Medicaid provisions, children are guaranteed only routine cleanings every six months. Any additional visits are determined by a dentist’s evaluation of the child – and that dentist’s request for approval to proceed. As CCMP has seen in practice, children are routinely denied necessary care.

CCMP knows it is going to take accountability to establish comprehensive healthcare in New York, which is why we need additional volunteer health professionals and organizers to build our fight. Call CCMP today at (718) 469-5817 today and ask for Simone or Tasluba.