Legal Aid, Willkie File Federal Class Action Lawsuit Against New York State for Denying Medicaid Recipients Necessary Dental Coverage

Litigation Could Potentially Benefit Thousands of Low-Income New Yorkers Suffering From State’s Flawed and Inadequate Medicaid Dental Program

The Legal Aid Society and Willkie Farr & Gallagher LLP today filed a federal class action lawsuit against the New York State Department of Health on behalf of two low-income Medicaid recipients in New York who have been denied coverage for medically necessary dental care by New York State – a violation of the Medicaid Act, Americans with Disabilities Act and Rehabilitation Act.

Plaintiffs Frank Ciaramella and Richard Palazzolo bring this suit on behalf of thousands of Medicaid-eligible New Yorkers whose expenses associated with medically necessary dental services are not reimbursable by New York’s Medicaid Program because of the Program’s categorical ban on dental implants and strict limits on replacement dentures. The suit asserts that the rigid rules in the NYS Medicaid Program Dental Policy and Procedures Code Manual restrict coverage for services that are necessary for Medicaid recipients to maintain their overall health. The current NYS rules ignore 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.

“Too many low-income New Yorkers lack coverage for basic oral health care and cannot afford to pay for necessary treatment on their own. This can carry disastrous health consequences and impact one’s ability to access housing, employment, and other lifelines,” said Belkys Garcia, Staff Attorney with the Law Reform Unit at The Legal Aid Society. “New York State has a legal and moral obligation to provide comprehensive dental coverage to poor New Yorkers, and we look forward to arguing this in Federal court.”

“The New York Medicaid program’s arbitrary restrictions on access to dental implants and replacement dentures plainly violate the Medicaid Act’s requirement to provide necessary care, but they also disregard the numerous side effects of those rules on thousands of low-income New Yorkers relying on Medicaid for their dental care – including medical complications, social isolation and employability,” said Mary Eaton, partner at Willkie Farr & Gallagher LLP.

The current rules in the NYS Medicaid Program Dental Policy and Procedures Code Manual restrict coverage for services necessary for Medicaid recipients to maintain dental and overall health, declaring that “complete dentures and partial dentures will not be replaced for a minimum of 8 years from initial placement except when they become unserviceable through trauma, disease or extensive physiological change. Prior approval requests for premature replacement will not be reviewed without supporting documentation of medical necessity. Dentures which are lost, stolen or broken will not be replaced unless there exists a serious health condition that has been verified and documented.” The Manual also specifically excludes “dental implants and related services” from the scope of Medicaid coverage.

This suit is the latest example of New York State’s Department of Health denying medically necessary care to Medicaid-eligible recipients. In 2015, for example, DOH was found to have violated the Medicaid Act by refusing medically necessary care to transgender Medicaid recipients, Cruz v. Zucker. Legal Aid and Willkie Farr & Gallagher achieved this historic victory which secured transgender New Yorkers’ right to Medicaid coverage of medically necessary gender affirming treatment.

 

Background

Frank Ciaramella, 57, is a Medicaid recipient who suffers from end stage renal disease and receives dialysis three times a week. He also suffers from hypertension, coronary artery disease and diabetes. After having his teeth removed out of medical necessity, he received dentures in 2016, which became unusable due to damage and poor fit. With a renal condition that limits his fluid intake and no dentures to chew food, he is malnourished, making him more susceptible to disease.

Under current NYS Medicaid guidelines, he does not qualify for new dentures until 2024. After seeking treatment from an oral surgeon, who determined he would require two dental implants to hold new dentures in place, he was denied coverage for the implants by NYS, citing the service was not covered and not billable after placement of dentures.

Richard Palazzolo, 60, suffers from bipolar disorder, depression, anxiety, diabetes and back pain. He lives in  supportive housing. After his dentures were stolen in 2017, he requested replacement dentures, which was denied by NYS on the grounds that the service is only allowed one time every eight years. An administrative fair hearing subsequently upheld the denial. Denial of his replacement dentures violates the Medicaid Act’s Availability and Reasonable Promptness Provisions, which guarantee that Medicaid-eligible individuals have access to medically necessary covered services and that such services will be provided in a reasonably prompt period of time.

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