Following a historic settlement in Ciaramella et. al. v. Bassetta federal class action lawsuit, the New York State’s Department of Health (DOH) will be required to implement significant changes to the Medicaid dental benefit program.
These changes will expand dental coverage to approximately five million Medicaid recipients in New York.
Key changes to the Medicaid dental benefit program include:
- Coverage for crowns and root canals – The strict limit previously denying coverage for these procedures for individuals with more than four pairs of teeth will be eliminated. Coverage will now be approved when deemed medically necessary, including for balance and function.
- Crown lengthening — The categorical ban in this procedure will be eliminated, allowing for coverage as needed with a crown or root canal.
- Replacement dentures — Coverage will be provided as medically necessary, without requiring a physician to demonstrate that the replacements will “alleviate” the Medicaid recipient’s serious health condition.
- Dental implants and related services — The categorical ban on coverage for these services will be eliminated. Coverage will be provided as medically necessary, without requiring a physician to demonstrate that the replacements will “alleviate” the Medicaid recipient’s medical condition.
The settlement was achieved by The Legal Aid Society, along with law firms Willkie Farr & Gallagher LLP and Freshfields Bruckhaus Deringer LLP, who filed the lawsuit on behalf of Medicaid recipients denied coverage for medically necessary dental care by New York State.
The expanded dental coverage is expected to help Medicaid patients maintain better oral and overall health, with a focus on routine dental care and preventive procedures.
Belkys Garcia, a staff attorney with the Civil Law Reform Unit at The Legal Aid Society, criticized the settlement, noting that millions of New Yorkers on Medicaid will now have access to insurance for various dental issues essential to maintaining overall health.
“With this settlement, millions of New Yorkers on Medicaid across the state will now have access to insurance covering a range of dental issues central to maintaining one’s overall health,” said Garcia. “We brought this lawsuit to end New York’s long standing practice of denying our clients medically necessary care and will continue to do so as long as these injustices remain on the books. The Legal Aid Society lauds our Plaintiffs for their bravery and work on behalf of millions of New Yorkers to elevate this issue.”
Historically, dentistry and medicine have evolved as separate professions in the United States. Dentistry was not considered an integral part of medical care, and therefore, dental insurance was not included in general health insurance plans.
However, taking care of your teeth is essential for maintaining not only good oral health but also overall health. Poor dental hygiene and oral health have been linked to various health issues, including heart disease.
Research has shown that people with gum disease are at a higher risk of developing heart disease compared to those with healthy gums. Inflammation caused by gum disease is believed to contribute to the formation of plaque in the arteries, which can restrict blood flow and potentially result in a heart attack or stroke.