ILNews

Judge rejects dental coverage cap

Back to TopCommentsE-mailPrintBookmark and Share

When Sandra Bontrager tried to get Medicaid coverage for a costly dental surgery procedure two years ago, she didn’t think that her request would eventually lead to a federal lawsuit and a ruling striking down the state’s policy about how Indiana covers those Medicaid services.

But that is what happened on Nov. 4 when Chief Judge Philip Simon in the Northern District of Indiana ruled the state must fully cover dental services that are medically necessary for Medicaid participants and that it can’t cap coverage at a certain amount. The reason: limiting coverage would deny some low-income individuals the ability to get needed care.

Now, the Office of the Indiana Attorney General will likely appeal the Goshen woman’s case to the 7th Circuit Court of Appeals and the fate of the state’s policy remains uncertain. If upheld, the result could lead Indiana down a road other states have taken – scrapping dental coverage for Medicaid participants all together. If the judge’s ruling is overturned, then some people won’t be able to obtain coverage for certain dental service and, in effect, those procedures could be off limits to low-income Hoosiers.

“I think it’s great that Judge Simon’s ruling stands for the idea of entire participation,” said Indianapolis attorney Jackie Bowie Suess, who represents Bontrager in the federal suit. “If the state’s going to participate in an important federal program like Medicaid, it has to follow the rules. Everyone is sympathetic to budget concerns, but that doesn’t mean you have the right to deny people services when you’ve already promised them coverage to the extent the law requires.”

suess Indianapolis attorney Jackie Bowie Suess represents a woman who successfully challenged the state’s policy to only cover “medically necessary” Medicaid dental services costing less than $1,000. (IBJ Photo/ Perry Reichanadter)

This Indiana case is part of a bigger national discussion that involves adult dental benefits for low-income residents being eyed for reduction or elimination as states struggle with the effects of the recession and skyrocketing Medicaid enrollment. To contain costs, many states have been cutting back on optional benefits, including adult dental services, according to an annual 50-state survey released by the Kaiser Commission on Medicaid and the Uninsured.

Now, as Indiana’s coverage of these adult dental procedures remains in question, the state could be forced to address whether it can afford to maintain those services.

Simon’s recent ruling came 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, a case originally filed in Elkhart Superior Court but later removed to federal court.

The suit focuses on how Indiana participates in the federal Medicaid program and provides dental coverage. The state isn’t required to provide dental care reimbursements to low-income participants, but state officials have chosen to do that 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 requiring consistent, equal coverage for program participants.

Bontrager’s dentist determined in 2009 that she needed two implants and abutments for her lower jaw. Because she is a Medicaid program participant, 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 would 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. Prior to this year, the cap had been $600 per participant.

According to court filings, the state argues the cap is needed to potentially save millions of dollars annually and that it doesn’t impact most participants because 99 percent have annual dental costs less than $1,000. The state argues that invalidating that cap could lead to discontinuing the Medicaid dental program altogether. 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.

Saying that this dispute casts Indiana into the “byzantine world of state and federal Medicaid laws, regulations and cases,” Simon wrote that the case boils down to disagreement about what it really means to “cover” a procedure that’s been deemed medically necessary.

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

Simon addressed a question that remains unanswered by the 7th Circuit about whether a private cause of action is allowed under the federal Medicaid law. The state contends one doesn’t exist, but Simon disagreed and relied on a 1993 appellate decision – Miller ex. Rel. Miller v. Whitburn, 10 F.3d 1315, 1319-21 (7th Cir. 1993) – to find a private cause of action does exist. The appellate court hasn’t addressed the issue in the past decade, and this case could set the stage for that issue to be analyzed.

Simon also disagreed that the $1,000 cap is a “utilization control procedure,” something the state contends it is allowed to implement under federal law, although the law doesn’t define what that term means. The judge determined that utilization control procedures should be used to prevent fraud and paying for unnecessary services. Simon rejected Indiana’s argument that the $1,000 cap is a permissible limit on the “amount, duration, or scope” of a service as specified in both federal and state statute.

Even though state legislators could as a result of this ruling decide to stop providing dental care coverage to Medicaid participants, Simon said he’s not in a position to consider those public policy consequences and must follow precedent and the law.

“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,” he 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.’”

The state is still reviewing the ruling and has indicated a decision would be made by the end of November on whether an appeal will be filed, according to the federal court docket.

Suess said that the judge’s decision to strike down the cap is a very big deal for Bontrager. For the Goshen woman, the legal issues and federal court holding that could apply to thousands of Indiana Medicaid participants isn’t at the heart of this case.

“She’s been fighting, through the administrative appeal process, for years to try and get the dental services she needs in order to eat properly,” her attorney said. “Throughout this entire ordeal, she’s been unable to chew food normally and, therefore, eat normally. She’s ecstatic about the decision and is very excited to finally get the implants and dentures she needs. … I’m hopeful she can get them before Christmas to enjoy a full, healthy meal with her family during the holidays.”•

ADVERTISEMENT

Post a comment to this story

COMMENTS POLICY
We reserve the right to remove any post that we feel is obscene, profane, vulgar, racist, sexually explicit, abusive, or hateful.
 
You are legally responsible for what you post and your anonymity is not guaranteed.
 
Posts that insult, defame, threaten, harass or abuse other readers or people mentioned in Indiana Lawyer editorial content are also subject to removal. Please respect the privacy of individuals and refrain from posting personal information.
 
No solicitations, spamming or advertisements are allowed. Readers may post links to other informational websites that are relevant to the topic at hand, but please do not link to objectionable material.
 
We may remove messages that are unrelated to the topic, encourage illegal activity, use all capital letters or are unreadable.
 

Messages that are flagged by readers as objectionable will be reviewed and may or may not be removed. Please do not flag a post simply because you disagree with it.

Sponsored by

facebook - twitter on Facebook & Twitter

Indiana State Bar Association

Indianapolis Bar Association

Evansville Bar Association

Allen County Bar Association

Indiana Lawyer on Facebook

facebook
ADVERTISEMENT
Subscribe to Indiana Lawyer
  1. I can understand a 10 yr suspension for drinking and driving and not following the rules,but don't you think the people who compleate their sentences and are trying to be good people of their community,and are on the right path should be able to obtain a drivers license to do as they please.We as a state should encourage good behavior instead of saying well you did all your time but we can't give you a license come on.When is a persons time served than cause from where I'm standing,its still a punishment,when u can't have the freedom to go where ever you want to in car,truck ,motorcycle,maybe their should be better programs for people instead of just throwing them away like daily trash,then expecting them to change because they we in jail or prison for x amount of yrs.Everyone should look around because we all pay each others bills,and keep each other in business..better knowledge equals better community equals better people...just my 2 cents

  2. I was wondering about the 6 million put aside for common attorney fees?does that mean that if you are a plaintiff your attorney fees will be partially covered?

  3. My situation was hopeless me and my husband was on the verge of divorce. I was in a awful state and felt that I was not able to cope with life any longer. I found out about this great spell caster drlawrencespelltemple@hotmail.com and tried him. Well, he did return and now we are doing well again, more than ever before. Thank you so much Drlawrencespelltemple@hotmail.comi will forever be grateful to you Drlawrencespelltemple@hotmail.com

  4. I expressed my thought in the title, long as it was. I am shocked that there is ever immunity from accountability for ANY Government agency. That appears to violate every principle in the US Constitution, which exists to limit Government power and to ensure Government accountability. I don't know how many cases of legitimate child abuse exist, but in the few cases in which I knew the people involved, in every example an anonymous caller used DCS as their personal weapon to strike at innocent people over trivial disagreements that had no connection with any facts. Given that the system is vulnerable to abuse, and given the extreme harm any action by DCS causes to families, I would assume any degree of failure to comply with the smallest infraction of personal rights would result in mandatory review. Even one day of parent-child separation in the absence of reasonable cause for a felony arrest should result in severe penalties to those involved in the action. It appears to me, that like all bureaucracies, DCS is prone to interpret every case as legitimate. This is not an accusation against DCS. It is a statement about the nature of bureaucracies, and the need for ADDED scrutiny of all bureaucratic actions. Frankly, I question the constitutionality of bureaucracies in general, because their power is delegated, and therefore unaccountable. No Government action can be unaccountable if we want to avoid its eventual degeneration into irrelevance and lawlessness, and the law of the jungle. Our Constitution is the source of all Government power, and it is the contract that legitimizes all Government power. To the extent that its various protections against intrusion are set aside, so is the power afforded by that contract. Eventually overstepping the limits of power eliminates that power, as a law of nature. Even total tyranny eventually crumbles to nothing.

  5. Being dedicated to a genre keeps it alive until the masses catch up to the "trend." Kent and Bill are keepin' it LIVE!! Thank you gentlemen..you know your JAZZ.

ADVERTISEMENT