Low-income New Yorkers are now eligible for a root canal in their dental coverage

NEW YORK — For millions of low-income New Yorkers, access to routine dental care has long depended on whether or not they still have eight crucial teeth.

A mouth with only four pairs of identical posterior teeth is considered “adequate for functional purposes” under state guidelines for Medicaid recipients. And those who are considered functional, no matter how many other teeth are missing, aren’t covered for root canals and crowns, two of the most common procedures in the field.

Under a new legal agreement reached on Monday, the New York Department of Health must lift some of its most restrictive rules for Medicaid recipients, including the longstanding “eight points of contact” policy.

The change will expand dental coverage to about 5 million people, dramatically improving the oral health of low-income patients statewide, according to Belkys Garcia, an attorney for the Legal Aid Society, who filed the class action lawsuit. the federal court in 2018. . .

“Before that, the Medicaid program was really just a tooth extraction program,” Garcia said. “If you needed a root canal or a crown, the program was set up to pull your teeth out instead of treating them.”

Medicaid programs vary by state, and dental care is not a federally mandated benefit. A handful of states, including Alabama and Delaware, do not provide dental coverage for adult Medicaid recipients, while a dozen others provide emergency care only.

But states that offer the optional benefit must 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 taxi driver who had all but three of his teeth knocked out after contracting a mouth infection in 2010. He soon discovered that his dentures had slipped and the prevented from eating.

They told him he needed a dental implant, which is not covered by the state. Instead, he chose to eat without dentures, wearing down his gums and the remaining bone in his mouth. He will now need more complicated surgery, involving a possible bone graft, to attach the prostheses.

“If I could handle this right away, I wouldn’t have lost as many bones as I have,” Adinolfi said.

The agreement lifts the ban on covering dental implants. Replacement prostheses will also be considered 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 medical coverage” to all Medicaid recipients, spokesperson Cort Ruddy said in a statement. “This agreement recognizes the importance of oral health and affirms the state’s commitment to these people.

The Department of Health did not immediately respond when asked how much the expanded care would cost.

According to a report by the United States Centers for Disease Control and Prevention, studies have shown deep racial and economic disparities in oral health, and efforts to address disparities among adults have shown only progress boundaries.

New York’s rule change comes just as millions of Medicaid-eligible adults across the country will lose their dental coverage when the COVID-19 national 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.