NY Medicaid Patients Win Dental Settlement, Expanding Coverage for 5 Million

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A class-action lawsuit will expand the state’s Medicaid rules, which lawyers argued were “structured to pull your teeth rather than save them.”

By Andy Newman

Matthew Adinolfi, who has no top teeth and had no love life for over a decade, will be able to get implants so that he can kiss a woman without fear of his dentures falling out.

Blanca Coreas, who can’t eat anything firmer than mashed potatoes without her gums bleeding, will be able to take a bite of grilled meat.

Lillian Velazquez has now gotten the root canal that was denied for nearly five years.

A class-action suit that was settled on Monday will bring about a change that is as potentially transformative as it is mundane: coverage of common but costly dental procedures for the five million adults in New York State who are on Medicaid, including implants, root canals and replacement dentures.

The suit, filed in 2018 in federal court against the State Health Department, which oversees Medicaid in New York, charged the state with denying thousands of low-income New Yorkers medically necessary treatment.

Medicaid programs, which vary from state to state, are not required to cover dental care; several states do not. But under federal law, if a state Medicaid program does cover an optional category of care — such as dentistry, prescription drugs or optometry — it must cover all medically necessary care in that category.

The suit argued that dental health was essential not just to overall physical health but also to psychological well-being and the ability to find or keep a job.

“You need to have teeth to function in our society,” said Belkys Garcia, a lawyer with the Legal Aid Society, which filed the suit. “It impacts everything in your life — your relationships, how people see themselves, how others see you.”

For decades, Ms. Garcia said, New York’s coverage rules for Medicaid were “structured to pull your teeth rather than save them.” And because one of the main jobs of a tooth is to hold its neighbors in place, an extraction often has a domino effect: Losing teeth leads to losing more teeth.

“Once you start missing one tooth, the teeth start shifting,” said Victor Badner, chairman of dentistry at Jacobi Medical Center, a city-run hospital in the Bronx. Dr. Badner filed a declaration in the case describing the dental needs of one of the plaintiffs.

Under the newly covered benefits, he said, “The vast majority of patients who otherwise would end up losing more teeth may instead be able to save them.”

New York already had “one of the more generous” Medicaid dental programs in its range of services covered, said Colin Reusch, director of policy for Community Catalyst, a health care consumer advocacy group. But he added: “The devil’s in the details in terms of how these policies come into play for people who are in urgent need of specific care.”

Under the old rules, root canals and crowns on back teeth were covered only if a diseased tooth was essential to anchoring a denture or if extracting it was medically inadvisable. Replacements for broken or lost dentures were covered only if the dentures were at least eight years old. Implants were not covered at all.

The suit’s lead plaintiff, Frank Ciaramella, died in 2020. In 2018, his dentures were destroyed after he sneezed; they fell out and were run over by a car. Under the old limits, he was not eligible for new dentures until 2024.

Mr. Adinolfi, 65, former New York City cabdriver who is on disability for a back injury and lives upstate near Plattsburgh, had all but three teeth pulled around 2010 after contracting a mouth infection so severe doctors feared it would spread to his organs.

“It was either pull the teeth out or die,” he said.

The dentures he received through Medicaid never fit and would not stay in place, making them impossible to eat with. He eventually paid for a permanent bridge for his lower front teeth, but could not afford one in back. Years of using his upper gums to chew down on his bottom denture have left the gums damaged. He needs implants to hold his upper denture in place, but Medicaid did not cover them.

As bad as the discomfort and difficulty eating have been, the effect on his social life has been at least as bad.

He did not have a relationship for over 10 years “because I just get to a point where you want to take it to the next level, and then that’s it,” Mr. Adinolfi said. “If I take the denture out you can notice how sucked-in my face is — it’s just very embarrassing on my part.” (He now has a girlfriend for the first time since his teeth were pulled.)

The settlement obligates New York Medicaid to cover implants, replacement dentures and most root canals if a dentist authorizes the procedures.

The settlement also does away with a rule that denied coverage for many procedures to people who still had four matched upper and lower pairs of back teeth, which the state had “considered adequate for functional purposes.”

Mary Eaton, a lawyer with Freshfields Bruckhaus Deringer, which joined Legal Aid’s suit, said that the dental problems addressed by the rules were “issues that everybody faces, regardless of your economic status.”

But Medicaid recipients tend to have more, and more complex, health problems than the population at large, often the result of lifelong poverty and inadequate medical care. Ms. Garcia said she had seen many clients “take on terrible credit card debt” to pay for basic dental procedures.

The gaps in Medicaid’s dental coverage also worsened racial health disparities. Ms. Garcia said that Black and brown adults suffer from untreated dental disease at nearly twice the rate as white adults.

The State Health Department, which twice attempted to get the case dismissed, said in a statement Monday afternoon that the settlement “recognizes the importance of oral health and affirms the state’s commitment” to people on Medicaid.

Wesley R. Powell, a lawyer with Willkie Farr & Gallagher, which also joined Legal Aid in the suit, said that in the long run, because so many teeth will be saved from extraction, the changes may well save the state money.

Ms. Coreas, 62, an ex-cafeteria worker in the Bronx, is another plaintiff in the lawsuit. Her dental problems have led to digestive problems, vitamin deficiency, frequent oral bleeding and depression, according to the lawsuit. She said she isolated herself socially because people sometimes made fun of her appearance.

In 2019, when Medicaid rejected a request for implants, which she needs to effectively wear dentures, she thought about suicide. “I felt like I had no support from anyone,” she said.

Ms. Velazquez had had an upper molar filled a number of times, but the filling kept falling out. Her dentist said the tooth needed a root canal and crown but Medicaid would not cover it, noting that extracting the tooth would still leave her with four matched pairs of back teeth.

For years she avoided eating on the left side to preserve the delicate tooth. She went through tube after tube of over-the-counter tooth cement. Under an agreement reached before the settlement, Medicaid covered her root canal.

Mr. Adinolfi’s path to dental functionality will be more arduous. He has lost so much bone above the gum that he may need a graft of bone from elsewhere in his body or implants anchored into his cheekbone. He faces months of surgeries and many hours in the dentist’s chair.

“I can’t wait,” he said. “I can’t wait.”

Andy Newman writes about social services and poverty in New York City and its environs. He has covered the region for The Times for 25 years. More about Andy Newman