The Legal Aid Society, Willkie Farr & Gallagher LLP, and Freshfields Bruckhaus Deringer LLP have announced a settlement in Ciaramella et. al. v. Bassett – a federal class action lawsuit brought against the New York State Department of Health (DOH) in 2018 on behalf of Medicaid recipients in New York who were denied coverage for medically necessary dental care by New York State. The settlement will result in changes to law mandating expanded dental coverage to New Yorkers who use Medicaid, including both new dental coverage benefits and a significant broadening of existing benefits, impacting approximately five million New Yorkers statewide.
Most significantly, the settlement terminates the strict limit denying coverage for crowns and root canals to individuals with more than four pairs of teeth, an archaic policy not aligned with modern United States dental practice. Coverage for those procedures will now be approved for Medicaid recipients when deemed medically necessary, including for balance and function.
The changes to the Medicaid dental benefit program focus on added coverage for routine dental care and procedures to help Medicaid patients preventatively maintain better oral and overall health. These changes are expected to result in long-term cost savings for New York State and its taxpayers by allowing Medicaid recipients to immediately address dental needs before they worsen and significantly impact overall health, requiring additional dental and/or medical attention.
Under the terms of the settlement, the DOH is required to adopt and implement the following changes to the Medicaid dental benefit program:
•Crown and root canal coverage – DOH will terminate the rule which denied coverage for root canals and crowns if a person had at least eight back teeth (four pairs) touching. Crowns and root canals will now be covered when medically necessary, including for balance and function. DOH guidance will explain medical necessity and will include crown and root canal coverage when: a medical condition prevents extraction; when the tooth is needed to secure an existing or proposed prosthesis, such as a removable denture; when the molar tooth is needed to maintain a balanced and functional bite; and when a person has eight or more natural or prosthetic back teeth in contact.
•Crown lengthening – The categorical ban on crown lengthening is eliminated, and this procedure will be covered as needed with a crown or root canal.
•Replacement dentures – These will be covered as medically necessary, without a physician having to show that the replacements will “alleviate” the Medicaid recipient’s serious health condition.
•Dental implants and related services – The categorical ban on coverage of dental implants and related services is eliminated. These will be covered as medically necessary, without a physician having to show that the replacements will “alleviate” the Medicaid recipient’s medical condition.
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