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Indiana can't cap Medicaid coverage of dental services

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A northern Indiana federal judge has ruled that the state must fully cover dental services that are medically necessary for Medicaid participants, and it can’t deny coverage exceeding a certain amount because that would prevent some low-income individuals the ability to get needed care.

The ruling from Chief Judge Philip Simon in the Northern District of Indiana came Friday in the class-action lawsuit of Sandra M. Bontrager v. Indiana Family and Social Services Administration, Michael A. Gargano and Patricia Cassanova, No. 3:11-cv-216.

Indiana isn’t required to provide any dental care reimbursements to low-income individuals participating in Medicaid, but the state’s chosen to do so through a process outlined in 405 Indiana Administrative Code 5-14-1. If a state chooses to provide benefits, it must comply with federal Medicaid law.

Enrolled in the Medicaid program, main plaintiff Sandra Bontrager’s dentist in 2009 determined she needed two implants and abutments for her mandibular jaw. The dentist submitted a request to the private company contracted to handle the state’s preauthorization process and determine whether a procedure is medically reasonable and necessary as defined by state administrative code.

Although the contractor initially determined the requested services weren’t “covered dental services,” more than a year of appeal procedures determined those were medically reasonable and necessary. Bontrager resubmitted the preauthorization request with an expectation she’d be able to get the dental work done.

However, the Indiana Family and Social Services Administration responded in 2011 that even with the determination that the dental work was covered and medically necessary, a new state regulation that began Jan. 1, 2011, limited total dental service reimbursement to $1,000 per person during any 12-month period, regardless of the medical reasonableness or necessity.

According to the court ruling, the cap was put in place to potentially save millions of dollars annually and 99 percent of Indiana Medicaid participants have annual dental costs less than $1,000. The state argues that invalidating that cap could lead to discontinuing the Medicaid dental program altogether, meaning that no participant would receive dental care.

“This dispute casts us into the byzantine world of state and federal Medicaid laws, regulations and cases,” Simon wrote. “At bottom, however, the parties essentially agree that these laws, regulations, and cases require the State to cover all medically necessary dental procedures. So, why are we here? Neither party frames their dispute quite this way, but their disagreement is really over what it means to ‘cover’ a procedure.”
 
The plaintiffs argue the state can only really cover a procedure by fully paying, while the defendants argue that it can cover those medically necessary expenses by partially paying for them.

“I think this is a close question, but … I have decided that the State is required to fully cover medically necessary dental expenses,” Simon wrote, granting a motion for preliminary injunction against Indiana.

Specifically, Simon found that a 7th Circuit Court of Appeals ruling in 1993 – Miller ex. Rel. Miller v. Whitburn, 10 F.3d 1315, 1319-21 (7th Cir. 1993) – is controlling precedent in the question of whether the state’s “minimum services” and “comparability of services” provisions of the federal Medicaid law create an unambiguous private right of action, in light of subsequent precedent from the Supreme Court of the United States in 1997 and 2002.

If the issue had been one of first impression, Simon wrote that he’d have determined the plaintiffs didn’t have a private cause of action and couldn’t proceed. But he’s constrained by Miller and found the plaintiffs have that ability to move forward with the class action.

“I fully understand the State’s attempt to limit the costs of its Medicaid program, particularly given the severe economic downturn and the attempt by governments around the country to implement austerity measures,” Simon wrote. “But a slew of cases hold that no matter how ‘pressing budgetary burdens may be … cost considerations alone do not grant participating states a license to shirk their statutory duties under the Medicaid Act.”

Indiana's attorney general has not decided whether the state will appeal the ruling, according to AG spokesman Bryan Corbin. A telephone conference hearing is set for Thursday to discuss the status of the suit and to review case management plans.

 

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  • Dental coverage
    I believe that Medicaid and Medicare should pay all dental coverage. They say that bad teeth can lead to health problems. So with Medicare and Medicaid not covering hardly any dental procedures, they are telling us that they don't care about people with low incomes health.
  • Osteonecrosis/Factor IV Leiden
    I have suffered from osteonecrosis for almost 20 years. Before mky dental insurance ran out, I had the remaining teeth removd because I could not continue in that kind of pain. NOw my jaw continues to shrink at a rapid rate. I managed to pay for 2 posts but now I cannot afford the bottom plate because even though the plate is covered by medicaid, the 2 "O" rings needed to lock the plate in place are not covered by medicaid. Medically I neeed posts on the top jaw now to help slow down the shrinking. If I cannot get Medicaid to cover these costs my face will end permantly disfigured.
  • disagree
    @Sara. Sure there are ones that do not brush because they dont care, but then you have people like me that grew up in foster care were we were not taught to brush our teeth because the foster parent didnt care if we did or not and a tube of toothpaste had to last all 4 of us 2 months if it didnt last we didnt get more till our bi-monthly allowence from the city came in. so i spent 10 years of formative ages not being taught to brush my teeth.

    @Elleen Yeah how can they say that when medicaid wont cover alot of work. I have severe asthma, my new dentist who i love wanted to send me to a oral surgeon so i could be sedated because i have had asthma attacks from noviacane use and severe anxitey attacks but medicaid wont cover the sedation.... that means i now have to take my emergancy inhaler and my nebulizer to my dental appointment to have some work done incase i have a problem.
  • i disagree
    My son has Medicaid and was at the dentist office today. He may need a root canal and crown, but Medicaid will not pay for the crown, so do not go as far to say that Medicaid patients do not brush their teeth and the taxpayers will pay the bill because there is no limitations. My son has ulcerative colitis and doctors have said that he has bad teeth due to all the nutrients he has lost with his disease. He DOES brush his teeth! No the state won't pay for all his dental work! He has Medicaid because his colitis makes him "uninsurable" so do not say Medicaid will take care of the bill.
  • Dental professional disagreement!
    As a member in the dental health field, I find this so disturbing and wrong. What about Americans who don't have any dental coverage and do not qualify for medicaid...surely they have to set there own "dental budget cap". Or those who have dental insurance...those people usually have co-pays and max out benefits around $1,500. They are working for those benefits too! If i were to treat a patient who has medicaid: I can do 20 fillings and the state is responsible for the bill. Do i need to remind you how that patient ended up with 20 fillings. It is because the state can't go into their bathrooms with them and brush their teeth for them! We are not doing a service to our society by removing this dental cap of 1,000 dollars worth of FREE dentistry. All we are doing is increasing our debt for taxpayers and growing the sense of entitlement these medicaid patients have. Dont brush your teeth, smoke all the cigarettes you want and consume all the junk food in the world because when I get a tooth ache, the taxpayers will take care of me with not limitations. Judge, I urge you to see first hand the patients I treat on medicaid and tell me if we are doing them a true service. Medicaid was not designed to be a free for all benefit or for dentist to make money off of by doing thousands of dollars worth of treatment that they know medicaid will take the bill.

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  1. Am I the only one who sees that the City is essentially giving away the MSA site AND giving millions to build new buildings on the site when this site would be the perfect place for the Justice Complex? Across from City-County, check; keeping it centrally located, check, etc. It's my understanding that the GM site must be purchased by the City from Motors Liquidation Company. STOP WASTING WHAT WE ALREADY HAVE AND OUR TAX DOLLARS! The Ballard Administration has not been known for it's common sense...never voted for him and never will!

  2. This guy sounds like the classic molester/manipulator.

  3. Louis D. Brandeis was born in 1856. At 9 years of age it would have been 1865. The Brandeis family did not own slaves. My source Louis D. Brandeis: A Life, by Melvin L. Urofsky.

  4. My name is Matthew Lucas Major, I recently went through a jury trial in Bloomington , In. It was the week of Feb 19-21. Although I have been incarcerated since August 5, 2014. The reason I 'am writing to you sir is on the 21 of February the jury came in with a very excessive and wrongful verdict of guilty on 6 child molesting charges against my daughter who was 9 at the time I was accused. I also had 2 other Felonies one of Intimidation and 1 of Sexual Vicarious Gratification. Judge Marc Kellam on the second day of trial gave me a not guilty on those 2 felonies. The jury was sent out during that time and when brought back Judge Kellam told them to not concern themselves with the 2 Felonies that he ruled on them. They were told to not let evidence they had already heard influence there verdicts. I never in my life touched any child sexually and definitely not with my own daughter. When I was arrested Detective Shawn Karr told me I would be convicted guilty just on my daughters word even without evidence. That's just what happened. my public defender did me so wrong he never once proved to the court and jury all the lies the child told, and Jeremy Noel my public defender could of proven the lies easily. The stories in Serenity's depositions and Forensic interview changed and were not consistent as Prosecutor Darcie Fawcett claimed they were. Yet my attorney never mentioned that. The facts that the child accused me of full penetration in her vagina and rectum was proven lies. Doctor Roberta Hibbard of Riley hospital in Indianapolis confirmed Serenity's hymen intact, no scars, no tearing, no signs of rape to her. Yet my attorney didn't use that knowledge . the DNA was all in my favor. I tell you I will spend my entire life in prison going through rape and beatings etc. even Judge Kellam abused his authority by telling the jurors to listen and believe what the prosecutors side in evidence like my daughters testimony. In one interview with the detectives my daughter got flustered with her mom and said on camera " I'm saying what you told me to mom"!! Yet Mr. Noel said nor did anything to even resemble a defense attorney. Judge Kellam allowed edited version of a taped conversation between the child and her mother. Also Judge Kellam allowed the Prosecutor too bring in to my case a knife found under my seat, the knife wasn't part of my case. She was allowed by my attorney and the judge to put a huge picture of it on the screen and huge picture of my naked privates in a full courtroom and open court. Ms. Fawcett says to jury see how easy Mr. Major could reach the knife and cut his Childs throat. Even though I had no weapons charge against these cases. This gave the jurors prejudice thought against me thinking I threatened her with that knife and how scared she would of been knowing i could get it and kill her. On my sentencing court March 19, 2014 my public defender told Judge Kellam he wish to resign from being my attorney and wished for the court to give me outside council to file a error to trial or appeal. We were denied. Now after openly knowing my public defender don't want to represent me he has to. Well when as parents we make our kids clean a room when they really don't wish to, well the child will but don't mean she will do a good job, that's where I'm at with Mr. Noel. please dont ignore mine and my families pleas for your help . we have all the legal proof you could need to prove Im innocent. Please dont make my spend years in prison innocent when you can fix this wrong. Im not saying Im a perfect man or that I was a perfect dad to my 2 children none of us are. Ive made some bad choices in life and I paid for them. But I didnt ever touch or rape my daughter . I love my children with all my heart. And now through needing attention and a ex-wife who told my granny several times she wish she could put me in prison to get me out of their lives. Well my ex finally accomplished her goal. Sad part is she is destroying our daughter with all this horrific lies and things she taught my daughter to say. My daughter will need therapist to ever hope for a chance of a normal life after what she had done to her by her mom and their side of the family. My daughter told everyone even on stand she had a dream months before i supposedly molested her in this dream I was molesting her and when I finally did it matched her dream perfectly. She admitted to watching movies about little girls being molested and watching U-Tube videos about child molesting all before it happened supposedly to her. Doesn't that sound very unusual that a non molested 9 yr old would need to know so much about being molested? The only reason I could think a 9 year old would need so much information is to be prepared to know what to say and be able to say how it felt what took place etc.. So when questioned by authorities she would be prepared. And there again sir if a parent is pre grooming a 9 year old child she would need intimate details . Like telling her daughter about a couple moles on my private area. The child admitted to sneaking my cell and looking many many times at nudes of me and my girlfriend even one where my penis was entering my girlfriends vagina. In that picture my moles are obvious. Yet when prosecutor showed everyone in court my privates and pictures of the moles she said the only way the child would know about them is if she saw them for herself. My attorney once again said nothing about the pictures my child saw. Or could a ex-wife be able to describe my moles to help her case against getting rid of me? I beg you help me. This is my very existence. Ive lost everything , a good job, a wonderful girlfriend, my freedom, but worse thing Ive lost is my children. They were my reason to get up every morning and strive to be better. The wonderful bond I had with my Serenity is gone. After this I would be afraid to even hug her for fear of what next can they do to me. I'm not afraid to tell you I sit here in this cell and try to hold back my tears. Everyone knows you cant show weakness in prison. My life has already been threatened here at Wabash Valley Prison. After only 3 days of arrival. I was tricked into signing a waiver now Im in G Block General Population with 6 child molesting felony charges. Mrs. Hart as a 18 year old I almost died hooked to machines in hospital almost 1 month and now I know that fear was childish compared to this . I cant help but put emotions in this, after all Mrs. Hart Im human and God help Me I never been more afraid in my life. I didnt hurt my little girl I didnt touch her sexually. As much as it shreds me and fills my mind what Im facing I worry more about my mom and granny because of their great love for me mam they are suffering so deeply. I aint done this things but my loved ones suffering right along beside me and If you take my case you will be in essence freeing them also. I sent momma this letter and asked her to email it to you. I'm scared I have been done so unjustly by our legal system and I need you to fix this and give me freedom. I ask you please don't just ignore my pleas. Here in America its nice to be able to trust our legal justice system, well they destroyed my and my loved ones trust in our justice system . And I'm trusting in You !!! My entire family is suffering this nightmare with me. My 77 year old granny had a stroke and isn't doing so well. My single mother that raised 3 kids alone is dying from Lupus and since my arrest has stayed so sick and weary. Our lives torn to peices by a government I was taught I could trust in. my momma has tried so many innocent project and wrongfully accused and cant get anywhere. please please help me. A quote from the late Nelson Mandela: To be free is not merely to cast off ones chains, But to live in a way that respects and enhances The Freedom Of Others. I have Faith in you and your clinic to cast my chains off and give me freedom I do deserve as a wrongfully accused Man, son, brother, father, friend. Matthew Major DOC# 246179 Cause # : 53c02-1308-FA-000779 God Bless you. Please contact me with your decision so I know you made a life changing decision for me , just please at least write me so I know you care enough about your citizens to respond to cries for your help. You can speak openly with my mother Charlotte Spain (828) 476-0406: 71 Lakeview Dr. Canton, NC 28716 Thank You Matthew Major I know yall get thousands of request and inmates claiming innocence, and each person who are innocent deserve to have organizations like yours willing to fight for them and I give yall so much Thanks and I thank God everyday yall are out there caring enough to help free the innocents. Since discovering firsthand how easily lives and families can be destroyed by Poor Defense attorneys not doing their job . And Prosecutors allowed to do as they please in court

  5. Frankly, it is tragic that you are even considering going to an expensive, unaccredited "law school." It is extremely difficult to get a job with a degree from a real school. If you are going to make the investment of time, money, and tears into law school, it should not be to a place that won't actually enable you to practice law when you graduate.

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