May 2, 2023

Settlement expands NY’s Medicaid coverage for medically necessary dental procedures

By Tiffany Cusaac-Smith

Updated May 2, 2023 10:07 am

Roughly 5 million low-income New Yorkers who are on Medicaid will get expanded dental coverage, thanks to the settlement of a federal class-action lawsuit brought against the state Health Department.

A lawsuit that contended the state’s Medicaid rules denied basic dental care has been settled, expanding coverage for 5 million. Credit: Getty Images/David McNew

Crown placements and root canals were among several dental procedures the state routinely denied residents who use Medicaid, which provides health care to millions of low-income people. But the settlement, announced Monday, will make those procedures and others, such as replacement dentures, more readily accessible.

“We’ve reached a settlement that will change the rules and really drastically expand, I would say, the coverage around those specific benefits that will allow for necessary and basic dental care,” said Belkys Garcia, staff attorney with the Civil Law Reform Unit at The Legal Aid Society, which brought the lawsuit.

The Health Department said Monday, “This settlement recognizes the importance of oral health and affirms the state’s commitment to those individuals.”

Before the settlement, people could be denied coverage for a root canal if they had at least eight back teeth, according to Legal Aid. Crowns and root canals will now be covered when deemed medically necessary and it will be easier to get replacement dentures, dental implants, and related services, attorneys said.

The settlement comes after 10 original plaintiffs and others in the class “whose expenses associated with medically necessary dental services are not reimbursable by New York’s Medicaid program … because of the Program’s illegal limitations” brought the litigation in 2018, court papers say.

The suit argued that the state’s Medicaid program restricted coverage necessary to maintain overall health. It contended that adequate dental care was vital not only to a person’s physical and mental well-being but their ability to work and function in society.

The settlement includes the firms of Willkie Farr & Gallagher, and Freshfields Bruckhaus Deringer, which also represented the plaintiffs.

On Long Island, healthcare officials say the settlement is promising.

“I think that this is a very important achievement for folks when it comes to accessing dental care because there have been historically so many strict limitations, and many Medicaid recipients have received denials for things that are really necessities,” said Rebecca Sanin, president and CEO of the regional nonprofit Health and Welfare Council of Long Island.

Sanin said many of their clients on Long Island have to go through an appeals process only to end up being denied restorative dental care.

Audrey Smith, CEO of Long Island Select Healthcare, a federally qualified health center that serves many low-income clients, said dental procedures are one of the most challenging areas in health care because coverage doesn’t always align with what people need.

At the health center, what typically happens when a person can’t pay for a crown or other restorative care is that they could be placed on a payment plan or a sliding scale.

The settlement, she said, would be a benefit for many of the people the health center serves, but that there are also other pressing needs, mainly the lack of dentists on Long Island who care for people on Medicaid.

“The availability of dentists is our biggest issue right now,” she said.

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