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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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