The Seventh Circuit Court of Appeals has upheld a ruling that says Indiana cannot set a thousand-dollar cap on Medicaid coverage of dental procedures.
Sandra Bontrager hasn't been able to chew well for at least eight years. The 66-year-old from Goshen has dentures, but she says they don't work on foods like apples or salad. And sometimes they just fall out. Her dentist thought dental implants would work better. So she applied to receive them as a participant in the low-income health program Medicaid.
"I filed because I couldn't eat," said Bontrager. "I couldn't eat nothing solid and I had to chop everything. Do you know how embarrassing it is to ask a restaurant to chop your food?"
Indiana's Medicaid program considered the procedure to be "medically necessary" which meant normally it would have been covered. But in January 2011 the agency that oversees Indiana's Medicaid program, the Family and Social Services Administration, decided it would only cover a thousand dollars of the cost of any necessary dental procedure for a Medicaid recipient in a given year. Bontrager's dentist estimated her implants would cost seven times that amount. So Bontrager filed a lawsuit claiming the FSSA's budget-trimming move went against state and federal law. Last year, a federal district court issued an injunction against the limit. And Wednesday the Seventh Circuit Court upheld that ruling. Lawyer Jackie Suess represented Bontrager in both lawsuits on behalf of the ACLU.
"The recipients, of course, are all low income people who can't afford to pay for these services themselves," said Suess. "And that obviously is – there's a much greater harm to them from not granting the injunction than there would be to the state saving a relatively small amount of money."
Indiana Dental Association Governmental Affairs Director Ed Popcheff says ultimately all parties lose money when Medicaid recipients can't access the care they need and end up with sometimes life-threatening conditions.
"Providing some level of benefit makes more sense than providing no benefit and having patients access the emergency room for their dental care," said Popcheff.
A spokesperson for the FSSA would not comment, but in a written statement said the FSSA "believes" the cap is " a reasonable and appropriate way to address budgetary concerns and still provide adequate dental coverage for the vast majority of Indiana Medicaid recipients." It also says the agency has not decided whether to will appeal the ruling.
