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.