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Medicaid Dental Benefit in NYS
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Views: 293421
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Posted: 10 Mar, 2015
by Arielle McTootle (Legal Aid Society)
Updated: 18 May, 2023
by Rebecca Novick (Legal Aid Society)
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Under Medicaid, dental benefits exist, but the coverage is limited. However, coverage will be expanded soon (in approximately late 2023/early 2024) as the result of the settlement of the Ciaramella v. McDonald case (originally Ciaramella v. Zucker).
The limited coverage makes it important for advocates to understand the exceptions to different coverage limitations. By understanding the nuances of the benefit, advocates can help get their clients the coverage they need, both now and once the settlement goes into effect.
In August, 2018, The Legal Aid Society and Willkie Farr & Gallagher filed Ciaramella v. Zucker (18-cv-06945) to challenge the New York State Department of Health’s rules preventing Medicaid coverage for replacement dentures within 8 years from initial placement and the ban on Medicaid coverage for dental implants. In response, DOH implemented changes to the dental manual to cover dental implants when medically necessary and to change the rules for replacement dentures. These changes, described below went into effect on November 12, 2018.
The case was amended to include a challenge the revised rules for Medicaid coverage for dental implants, replacement dentures and to add a challenge to Medicaid coverage rules for root canal and crowns.
On May 1, 2023, a motion for preliminary approval for a settlement agreement was filed.
For more information about the lawsuit, see article in New York Times, August 2, 2018, "Lack of Dental Coverage Hampers Medicaid Recipients, Suit Says" and this article about the settlement, Hoping for a Root Canal: 5 Million New Yorkers Get More Dental Coverage.
If you need advice about a specific Medicaid dental case, you can contact The Legal Aid Society's Access to Benefits helpline at (888) 663-6880.
Revised policy effective November 12, 2018 - click on these links:
VI. Prosthodontics - Full and /or partial dentures
VIII. Implant Services
WHAT DENTAL SERVICES ARE COVERED UNDER MEDICAID?
THE FOLLOWING DENTAL SERVICES ARE EXCLUDED UNDER MEDICAID AND WILL NOT BE REIMBURSED
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Dental implants and related services (BUT THIS WILL CHANGE NOV. 12, 2018 to the following policy:
VIII. Implant Services (revised Nov. 12, 2018
Dental implants will be covered by Medicaid when medically necessary. Prior approval requests for implants must have supporting documentation from the patient’s physician and dentist. A letter from the patient’s physician must explain how implants will alleviate the patient’s medical condition. A letter from the patient’s dentist must explain why other covered functional alternatives for prosthetic replacement will not correct the patient’s dental condition and why the patient requires implants. Other supporting documentation for the request may be submitted including x-rays. Procedure codes and billing guidelines will follow.
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Fixed bridgework, except for cleft palate stabilization, or when a removable prosthesis would be contraindicated;
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Immediate full or partial dentures;
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Molar root canal therapy for beneficiaries 21 years of age and over, except when extraction would be medically contraindicated or the tooth is a critical abutment for an existing serviceable prosthesis provided by the NYS Medicaid program;
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Crown lengthening;
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Replacement of partial or full dentures prior to required time periods unless appropriately documented and justified as stated in the Manual -- see changes effective Nov. 12, 2018
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Dental work for cosmetic reasons or because of the personal preference of the recipient or provider;
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Experimental procedures
WHAT IF MEDICAID DENIES THE CLAIM?
RELEVANT REGULATIONS
FAIR HEARINGS
COMMON ISSUES
The Fair Hearings described below were decided based on the OLD denture Policy, which expires Nov. 11, 2018.
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Disease or extensive physiological change can include additional lost teeth, especially if an abutment for the current denture is lost or damaged. See, e.g., FH #6254420Y. (available here)
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If a recipient's health would be adversely affected by the absence of a prosthetic replacement, and the recipient could successfully wear a prosthetic replacement, such a replacement will be considered. In the event that the recipient has a record of not successfully wearing prosthetic replacements in the past, or has gone an extended period of time (three years or longer) without wearing a prosthetic replacement, the prognosis is poor. Mitigating factors surrounding these circumstances should be included with the prior approval request.
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“Complete or partial dentures will not routinely be replaced when they have been provided by the Medicaid program and become unserviceable or are lost within eight years, except when they become unserviceable through extensive physiological change. If the recipient can provide documentation that reasonable care has been exercised in the maintenance of the prosthetic appliance, and it did not become unserviceable or lost through negligence, a replacement may be considered. Prior approval requests for such replacements will not be reviewed without supporting documentation. A verbal statement by the recipient that is then included by the provider on the prior approval request would generally not be considered sufficient.” FH #6755535N (available here)
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Example: Appellant’s dentist requested prior authorization for denture replacement prior to the 8 year waiting period. Appellant testified that she lost her lower denture at home. Her looks and speech were unaffected but the lack of lower dentures were detrimental to her health because she was unable to eat the healthy diet required as an insulin-dependent diabetic. She was forced to eat by pressing food against her upper palate with her thumb. Agency denial upheld. Even though appellant could not eat the food she required for her diabetes, appellant presented no objective medical evidence to support her contention that her lack of the lower denture will cause her health to be compromised. Her testimony alone was insufficient; objective medical documentation is required. FH #6755535N. (available here)
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Example: Appellant requested replacement of broken denture prior to the 8 year waiting period. Appellant testified he was taking the denture out at night to clean when he accidentally dropped it on the floor and two of the teeth broke off. The Appellant stated that with the denture being broken, he is left without any teeth, natural or otherwise, in his mouth. He further stated that without the lower denture, he cannot use the upper one because he will just be hurting his lower gum. Agency denial upheld. Though the Appellant accidentally broke the lower denture, dentures which are broken will not be replaced unless they become unserviceable through trauma, disease or extensive physiological change. FH# 7315399K (available here)
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Exception: “Under certain circumstances the Agency will approve replacement of a lost partial denture, such as for a recipient whose mouth had undergone significant changes subsequent to the incident -- for example the loss of teeth.” FH 6394357J (available here)
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Root Canals
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For beneficiaries age 21 and older, molar endodontic therapy will be considered when (1) the tooth in question is a critical abutment for an existing functional prosthesis and (2) the tooth cannot be extracted and replaced with a new prosthesis. See Dental Policy and Procedure Code Manual, page 38.
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Denials have been overturned for:
MANY DENTAL CLINICS ARE COVERED UNDER MEDICAID
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In addition to a plan’s network of dental providers, plan members have the right to access dental services at the five New York Academic Dental Center clinics licensed under Article 28 of the NY Public Health Law.
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Dental clinics are reimbursed on a rate basis or through Ambulatory Patient Groups (APGs) such as hospital outpatient departments, diagnostic and treatment centers, and dental schools, are required to follow the policies stated in the Dental Provider Manual. See Dental Policy and Procedure Code Manual, page 8.
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Dental services at these clinics may be accessed without prior approval and without regard to network participation.
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The plan must reimburse the clinic for covered dental services provided to enrollees at approved Medicaid clinic rates.
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New York State Dental Centers:
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