NEW YORK -- For millions of low-income New Yorkers, access to routine dental care has long hinged on whether or not they still have eight crucial teeth.
A mouth with just four pairs of matching back teeth is considered “adequate for functional purposes,” according to the state’s rules for Medicaid recipients. And those considered functional, no matter how many other teeth they’re missing, aren’t covered for root canals and crowns, two of the field’s most common procedures.
Under a new legal settlement reached on Monday, the New York Department of Health must lift some of its most restrictive rules for Medicaid recipients, including the long-standing “eight points of contact” policy.
The change will expand dental coverage for an estimated 5 million people, dramatically improving oral health for low-income patients across the state, according to Belkys Garcia, an attorney with the Legal Aid Society, which brought the class-action suit in federal court in 2018.
“Before this, the Medicaid program was really just a tooth-pulling program,” Garcia said. “If you needed a root canal or a crown, the program was set up to pull your teeth rather than treat them.”
Medicaid programs vary across states and dental care is not a federally mandated benefit. A handful of states, including Alabama and Delaware, provide no dental coverage to adult Medicaid recipients, while roughly a dozen others offer care only in emergencies.
But states that do provide the optional benefit are required to cover all medically necessary care. The lawsuit argued that New York had imposed “rigid restrictions on crucial services,” leading to the denial of coverage for medically necessary care.
Among the plaintiffs was Matthew Adinolfi, a former New York City taxi driver who had all but three of his teeth pulled after contracting a mouth infection in 2010. He soon discovered that his dentures slipped, preventing him from eating.
He was told that he needed a dental implant, which isn’t covered by the state. Instead, he opted to eat without dentures, wearing down his gums and the remaining bone in his mouth. He’ll now require a more complicated surgery, involving a possible bone graft, in order to secure the dentures.
“If I was able to deal with this right away, I wouldn’t have lost as much bone as I’ve lost,” Adinolfi said.
The settlement eliminates the ban on covering dental implants. Replacement dentures likewise will be deemed medically necessary. The new rules will take effect 90 days after a court approves the settlement agreement.
The Department of Health is committed to providing “comprehensive health coverage” to all state Medicaid recipients, spokesperson Cort Ruddy said in a statement. “This settlement recognizes the importance of oral health and affirms the state’s commitment to those individuals.”
The health department didn't immediately respond when asked how much the expanded care would cost.
Studies have shown deep racial and economic disparities in oral health, and efforts to address the disparities in adults have shown only limited progress, according to a report by the U.S. Centers for Disease Control and Prevention.
The shift in New York’s rules comes just as millions of adults who benefit from Medicaid nationwide will lose dental coverage when the national COVID-19 Public Health Emergency expires later this month.
The Legal Aid Society worked on the lawsuit with two law firms, Willkie Farr and Gallagher and Freshfields Bruckhaus Deringer.
