As an enrollee in a Medicaid managed care plan, you must see health care providers, including dentists, who contract with your specific health plan. This is called going to an in-network provider. To find an in-network dentist, you should call the member services number on the back of your health plan card and ask which dentists near you take your plan. Your plan may also have a website to help you find an in-network dentist. You then need to go through the list to find a dentist you want to see. Unfortunately, even though plans are required to have accurate provider directories, these lists are often out of date and some providers on the list may not be accepting new patients so it might take time to find an in-network provider.

If a Medicaid managed care plan does not have an in-network dentist with appropriate training or experience to meet your needs or does not have an in-network dentist in your area with an available appointment, the plan must make a referral to an appropriate out-of-network dentist. The plan is required to coordinate care for enrollees, including helping to find an out-of-network dentist when necessary.

If your plan is not helping you, you should file a grievance with the plan. Your member handbook or member services representative should explain how to file the grievance. The plan must decide your grievance within 90 days after receiving the grievance.

If you are not satisfied with how your grievance is handled, you should also file a complaint with the New York State Department of Health via email at managedcarecomplaint@health.ny.gov or by phone at 800-206-8125.  If you are in a Medicaid managed care plan called a managed long-term care plan, you should file a complaint via email to mltctac@health.ny.gov or by phone at 866-712-7197. You don’t have to wait until you get a response to your grievance to file a complaint with the Department of Health.

If you were not able to find an in-network dentist and have found an out-of-network dentist who will serve you, contact your plan to ask them to help you coordinate this care. If this does not work, you can also ask the dentist office to submit a prior authorization request for the requested care to your Medicaid managed care plan. Your plan may deny the request because the provider is out-of-network, but they are required to send a written notice explaining the denial and how to appeal the denial.

If your plan denies an out-of-network referral, you will have to show that the plan does not have an in-network provider with an available appointment, the appropriate training and experience to meet your health care needs.

The New York State Department of Health has a list of dentists who accept Medicaid fee-for-service on its website here and here.

If you are unable to find a dentist who takes fee-for-service Medicaid, contact the Department of Health’s Medicaid helpline at 800-541-2831 and tell them that you need an out-of-network referral because there are no available dentists on their lists.

The information in this document has been prepared by The Legal Aid Society for informational purposes only and is not legal advice. This information is not intended to create, and receipt of it does not constitute, an attorney-client relationship. You should not act upon any information without retaining professional legal counsel.