May 1, 2023
On May 1, a historic settlement was announced 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 case was led by pro bono partner The Legal Aid Society, Willkie Farr & Gallagher LLP, and Freshfields Bruckhaus Deringer LLP.
The settlement is expected to impact approximately five million New Yorkers with Medicaid coverage statewide, resulting in landmark 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. The New York Times covered the news here.
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.
The case was first brought in August 2018 by Frank Ciaramella and Richard Palazzolo on behalf of tens of thousands of Medicaid-eligible New Yorkers whose expenses associated with medically necessary dental services were not covered by New York’s Medicaid Program because of the Program’s ban on dental implants and strict limits on replacement dentures. DOH responded by amending the Medicaid rules to allow coverage of these services in narrow circumstances, notably requiring people to get seriously ill before they could even qualify for treatment.
The suit argued that the rigid rules in the New York State Medicaid Program restrict coverage for services that are necessary for Medicaid recipients to maintain their overall health. The rules also ignored the close connection between poor oral health and other health problems suffered by the Medicaid-eligible population, including periodontal disease, gum disease, diabetes and related health complications.
This suit was the latest example of DOH using archaic rules to deny medically necessary care to Medicaid-eligible recipients. In 2016, DOH was found to have violated the Medicaid Act by banning medically necessary care to transgender Medicaid recipients in Cruz v. Zucker. Legal Aid and Willkie Farr & Gallagher LLP achieved this historic victory which led to a repeal of the ban and amended regulation, requiring Medicaid coverage for transgender New Yorkers seeking medically necessary gender affirming treatment.
The Willkie team was led by partner Wesley Powell and included associates Annie Houghton-Larsen, Timothy Ryan, and Sean Lavin.
