US District Court Rules that Massachusetts Medicaid Must Improve

The first few lines of Judge Zobel’s decision foreshadow her conclusion “Plaintiffs have demonstrated that defendants violated sections of the Medicaid Act that require prompt provision of services, adequate notice and treatment at reasonable intervalsâÂ?¦” This decision brings many improvements within the MassHealth dental program for young patients and their dentists. Even though Judge Zobel only applies her decision to those MassHealth enrollees under the age of 21, there will be positive effects for older enrollees.

The “First Joint Report on Proposed Remedial Program” of August 31, 2005, demonstrates the level of cooperation that Judge Zobel’s ruling inspires. Written by Health Care For All’s (HCFA) attorneys lead by Laurie Martinelli and S. Stephen Rosenfeld of Health Law Associates, and the Commonwealth, represented by Assistant Attorney General, James J. Arguin, the report outlines powerful changes in the MassHealth dental program.

The agreement allows some common dental procedures more often than before. MassHealth will pay dentists and dental hygienists to clean their patients’ teeth twice a year versus the former once per year allowance. Patients may receive plastic coatings or sealants that protect teeth from cavities on all of their back teeth instead of only on first and second molars. MassHealth will cover the cost of custom mouth guards for sports and to protect teeth from the effects of grinding.

Part of the agreement makes acceptance of MassHealth more palatable to service providers. Dentists will be able to limit their acceptance of MassHealth clients to any number they consider manageable. Prior authorization requires the dentists to submit a form to request coverage for a later service. Soon, fewer procedures will require prior authorization. The payments for services will increase. MassHealth will market these changes to dentists around the commonwealth to attract more providers.

Providers may find that it is not easy to sign up to be a MassHealth provider. The enrollment forms are different from private insurance companies. For example, some dental providers must include a federal corporate tax return with their MassHealth provider application. The rules of working with MassHealth will continue to be different from other insurance. Even as MassHealth adopts the use of a standard dental billing form, there are differences in how the dental staff will fill it out.

HCFA and the state representatives will examine other ways to increase the availability of dental services. One proposal allows pediatricians and other health care providers to apply fluoride varnish in non-dental settings. Another proposal increases the capacity of Community Health Centers like the East Boston Neighborhood Health Center. Another way to expand access to dental care may be to increase the capacity of current school-based dental programs and create more such programs. The same programs may become available to children in Headstart (the federally funded preschool program) and other day care settings.

Thanks to the new provisions of the MassHealth dental program, people with benefits can expect to find that many more dentists will sign up to provide their care. Enrollees will find that they receive their care faster. They will be able to maintain their oral health or improve it. Be patient. Many of the new rules will become effective sometime in 2006.