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As a result of The Legal Aid Society’s settlement in Ciaramella v. McDonald, Medicaid dental coverage rules for root canals, crowns, dental implants, and replacement dentures have changed for Medicaid patients.
To better understand the new rules and the answers below, it may be helpful to review a chart with tooth numbers.
The new rules are in the New York State Medicaid Dental Manual. There is also a Guidance document that helps explain the new rules and gives examples. The two documents give more information than you’ll find in this FAQ.
January 31, 2024
These new rules apply to Medicaid recipients 21-years-old and older who need Medicaid coverage for root canals, crowns, dental implants, and replacement dentures. (There are different rules for people under 21.)
Root canals, crowns, dental implants and replacement dentures for Medicaid recipients who are 21-years-old or older.
Crown lengthening is now covered by Medicaid when it is done as part of a medically necessary crown or root canal procedure. Refer to the section of this FAQ on crowns and root canals to determine when a procedure is considered medically necessary.
If you haven’t been to the dentist recently, please refer to this resource about how to access Medicaid benefits.
You can also bring the Guidance document with you to the dentist in case your dentist doesn’t know about the changes.
The new rules only apply to requests submitted on or after January 31, 2024. You should ask your dentist to resubmit the request so the new rules will apply.
If you already have an appeal filed for a denial of one of these services that was requested before January 31, 2024, it still may be best to ask your dentist to resubmit the request. But if you prefer, you can still go forward with the appeal. A fair hearing decision may order the Medicaid program to reconsider the request under the new rules. However, it may also affirm the denial under the old rules. An external appeal may overturn the denial or affirm the denial.
See this resource for more information on Medicaid appeals.
As of January 31, 2024, crowns are covered by Medicaid when medically necessary.
In deciding whether a crown is medically necessary, the Medicaid reviewer should consider a list of factors. You do NOT have to meet all of these factors:
If the tooth is a front tooth (teeth # 6, 7, 8, 9, 10,11, 22, 23, 24, 25, 26,27), the following additional factors will make it more likely that the crown would be covered:
If the tooth is a back tooth (teeth # 1, 2, 3, 4, 5, 12, 13, 14, 15,16, 17, 18, 19, 20, 21, 28, 29, 30, 31, 32), the following additional factors will make it more likely that the crown would be covered:
No. It is important to note that a crown SHOULD NOT be denied solely because you have too many teeth in your mouth. This rule is called the “8 points of contact rule.” It no longer applies to crowns.
A crown will be covered where there are 8 or more points of contact, unless there is a reason that the tooth needs to be pulled.
As of January 31, 2024, root canals are covered by Medicaid when medically necessary.
In deciding whether a root canal is medically necessary, the reviewer should consider a list of factors. You do NOT have to meet all of these factors:
If the tooth is a front tooth (teeth # 6, 7, 8, 9, 10,11, 22, 23, 24, 25, 26,27), the following additional factors will make it more likely that the root canal would be covered:
If the tooth is a back tooth (teeth # 1, 2, 3, 4, 5,12,13,14,15,16,17,18, 19, 20, 21, 28, 29, 30, 31,32), the following additional factors will make it more likely that the root canal would be covered:
No. It is important to note that a root canal SHOULD NOT be denied solely because you have too many teeth in your mouth. This rule is called the “8 points of contact rule.” It no longer applies to root canals.
A root canal will be covered where there are 8 or more points of contact, unless there is a reason that the tooth needs to be pulled.
Crown lengthening is covered by Medicaid only when it is done as part of a covered crown or root canal procedure.
As of January 31, 2024, the rules for replacement dentures for patients with Medicaid have changed. Replacement dentures are covered by Medicaid when medically necessary.
The New York Medicaid program will replace dentures every 8 years. If you need to replace them before 8 years, your dentist must fill out this form explaining why you need replacement dentures.
If you already had your dentures replaced once in the past 8 years and you need another replacement, your dentist needs to fill out this form explaining why you need replacement dentures and explaining the efforts taken to prevent the need for future replacements.
As of January 31, 2024, the rules around dental implants for patients with Medicaid have changed. In many cases, dental implants are covered by Medicaid when medically necessary.
In deciding whether a dental implant is medically necessary, the reviewer will consider the complete treatment plan and this form submitted by your dentist that includes:
Medicaid will review the explanation of why you can’t wear dentures based on how many and which teeth you’re missing. This is because the rules for Medicaid coverage for your first set of dentures have not changed. Medicaid will cover dentures if you do not have 4 sets of top and bottom teeth in the back of your mouth that touch, or if you are missing one tooth on the top or two front teeth on the bottom.
Please refer to this resource for information about appealing a Medicaid denial.
If your request is for a root canal, crown, replacement dentures, or dental implants and the denial says it is not a covered benefit, this notice is wrong.
Contact the Department of Health to complain about this notice from the plan. Phone: 800-206-8125 Email: managedcarecomplaint@health.ny.gov Mail:NYS Department of Health, Managed Care Complaint Unit, OHIP DHPCO 1CP-1609, Albany, NY 12237
This contact information can be found here.
The plan should send another notice. The new notice may still be a denial, but it can’t be denied because the services is not a covered a benefit.
You must file your appeal within the deadlines.
The new rules only apply going forward. You will not be paid back money spent out-of-pocket for services you received before the new rules went into effect (January 31, 2024).
Please contact The Legal Aid Society’s Access to Benefits helpline Monday – Friday 10:00 a.m. to 3:00 p.m. at 888-663-6680.
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.