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State cannot enforce $1,000 cap on dental services for Medicaid recipients

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The 7th Circuit Court of Appeals has left in place the preliminary injunction granted by Chief Judge Philip Simon last year that prevents the state from capping dental work for Medicaid recipients at $1,000 a year.

Indiana Medicaid covers certain dental procedures that are “medically reasonable and necessary.” The state implemented the cap beginning Jan. 1, 2011, as a cost-cutting measure. Sandra Bontrager, who is on Medicaid, needs extensive dental work that will exceed the $1,000 cap.

In Sandra M. Bontrager, on her own behalf and on behalf of a class of those similarly situated v. Indiana Family and Social Services Administration, Michael A. Gargano and Patricia Casanova, the Circuit judges affirmed that Bontrager has a private right of action under 42 U.S.C. Section 1983 to challenge the cap.

The state claimed the cap does not prevent coverage of any medically necessary dental procedures, but operates as an appropriate limitation authorized by 42 C.F.R. Section 440.230 and I.C. 12-15-21-3(3).

“We agree with the district court that the cap prevents the State from providing coverage for all medically necessary services, and partial payment for such services does not constitute ‘some coverage,’ as the State would have us believe,” Judge Michael Kanne wrote.

The cap denies coverage for medically necessary services outright by functionally excluding certain procedures, the court held, and the cap is not in any way based on degree or consideration of medical necessity. It doesn’t matter, as the state asserts, that more than 99 percent of dental procedures needed by Medicaid recipients would be covered under the $1,000 cap.

The 7th Circuit also rejected the state’s claim that the cap is a “utilization control procedure.”

“Although we are mindful of potential budgetary concerns, these interests do not outweigh Medicaid recipients’ interests in access to medically necessary health care,” Kanne wrote. “The State cautions that it may end coverage of all dental services under its Medicaid plan if the $1,000 cap is no longer in place. Thus, this lawsuit may result only in a pyrrhic victory for the plaintiff. But the State’s likely violation of state and federal law cannot be ignored in order to preserve the status quo. Moreover, there are other avenues by which the State can limit its exposure to significant Medicaid costs.”

 

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  1. I grew up on a farm and live in the county and it's interesting that the big industrial farmers like Jeff Shoaf don't live next to their industrial operations...

  2. So that none are misinformed by my posting wihtout a non de plume here, please allow me to state that I am NOT an Indiana licensed attorney, although I am an Indiana resident approved to practice law and represent clients in Indiana's fed court of Nth Dist and before the 7th circuit. I remain licensed in KS, since 1996, no discipline. This must be clarified since the IN court records will reveal that I did sit for and pass the Indiana bar last February. Yet be not confused by the fact that I was so allowed to be tested .... I am not, to be clear in the service of my duty to be absolutely candid about this, I AM NOT a member of the Indiana bar, and might never be so licensed given my unrepented from errors of thought documented in this opinion, at fn2, which likely supports Mr Smith's initial post in this thread: http://caselaw.findlaw.com/us-7th-circuit/1592921.html

  3. When I served the State of Kansas as Deputy AG over Consumer Protection & Antitrust for four years, supervising 20 special agents and assistant attorneys general (back before the IBLE denied me the right to practice law in Indiana for not having the right stuff and pretty much crushed my legal career) we had a saying around the office: Resist the lure of the ring!!! It was a take off on Tolkiem, the idea that absolute power (I signed investigative subpoenas as a judge would in many other contexts, no need to show probable cause)could corrupt absolutely. We feared that we would overreach constitutional limits if not reminded, over and over, to be mindful to not do so. Our approach in so challenging one another was Madisonian, as the following quotes from the Father of our Constitution reveal: The essence of Government is power; and power, lodged as it must be in human hands, will ever be liable to abuse. We are right to take alarm at the first experiment upon our liberties. I believe there are more instances of the abridgement of freedom of the people by gradual and silent encroachments by those in power than by violent and sudden usurpations. Liberty may be endangered by the abuse of liberty, but also by the abuse of power. All men having power ought to be mistrusted. -- James Madison, Federalist Papers and other sources: http://www.constitution.org/jm/jm_quotes.htm RESIST THE LURE OF THE RING ALL YE WITH POLITICAL OR JUDICIAL POWER!

  4. My dear Mr Smith, I respect your opinions and much enjoy your posts here. We do differ on our view of the benefits and viability of the American Experiment in Ordered Liberty. While I do agree that it could be better, and that your points in criticism are well taken, Utopia does indeed mean nowhere. I think Madison, Jefferson, Adams and company got it about as good as it gets in a fallen post-Enlightenment social order. That said, a constitution only protects the citizens if it is followed. We currently have a bevy of public officials and judicial agents who believe that their subjectivism, their personal ideology, their elitist fears and concerns and cause celebs trump the constitutions of our forefathers. This is most troubling. More to follow in the next post on that subject.

  5. Yep I am not Bryan Brown. Bryan you appear to be a bigger believer in the Constitution than I am. Were I still a big believer then I might be using my real name like you. Personally, I am no longer a fan of secularism. I favor the confessional state. In religious mattes, it seems to me that social diversity is chaos and conflict, while uniformity is order and peace.... secularism has been imposed by America on other nations now by force and that has not exactly worked out very well.... I think the American historical experiment with disestablishmentarianism is withering on the vine before our eyes..... Since I do not know if that is OK for an officially licensed lawyer to say, I keep the nom de plume.

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