Come March 1, dental options will narrow drastically for adults on Medicaid in Montana, although children also will see some effects.
The Montana Department of Health and Human Services issued proposed rules on Jan. 12 that spell out what dental procedures will be impacted. The rules go into effect on March 1.
A public hearing will be held Thursday at the DPHHS building in Helena. Comments must be submitted by Feb. 9.
If adopted as-is, coverage will end for dentures, crowns and bridges for adults. Comprehensive orthodontic treatment will only be available to children up through age 20 grappling with specific conditions, such as cleft palate or a severe overbite.
“These budget cuts will mostly impact elderly and disabled adults in very critical ways,” said David Hemion, executive director of the Montana Dental Association.
But the change in the rule-making will also make it “more restrictive, more difficult for children who have need of orthodontic treatment to be qualified,” he said.
The decrease in services comes as a result of budget cuts adopted by Gov. Steve Bullock and the Legislature during the special session in November. The actions were in response to an anticipated revenue shortfall and the most expensive fire season in state history.
Cuts to dental services total $8.9 million. That includes $2.4 million in state money for the Medicaid dental program, which triggers a loss of nearly $4.6 million in federal dollars.
Another $1.9 million in state and federal funds has been trimmed from the children’s orthodontia program over the next two years.
Under federal law, states must provide dental care to children enrolled in Medicaid and the Children’s Health Insurance Program, Hermion said. That isn’t the case for adults.
Probably about two-thirds of dentists in Montana accept Medicaid patients, a high number compared to other states, he said.
“At times they may limit the number of patients they can see,” Hermion said. “The fee scheduled is less than their cost of that care they’re providing.”
Dr. Remington Townsend, a Billings dentist with three offices in Billings, as well as in Hardin, Red Lodge, Dillon and Big Timber, said the number of Medicaid patients his practice sees varies by office.
“Each one is just a little bit different,” he said. “Hardin has a large percentage, in Billings not so much and Laurel a little bit more than Billings.”
With his Medicaid patients up until now, Townsend has been able to choose the procedure that best meets his patients' need, whether that be a filling, a crown or a root canal.
“You don’t want to do a root canal or crown and leave teeth with decay,” he said. “You try to help the patient and save as many teeth as you can.”
If the proposed rule changes are adopted, his options will include filling cavities or pulling teeth. Not being able to provide dentures “is the one that’s really tough,” Townsend said.
“Without dentures, they age faster, their face gets sunken in and they look very different,” he said. “It’s a big change and it can compound the difficulty for someone trying to turn their life around.”
Another aspect to the dental cuts is the possible 2.99 percent cut to the overall rate dentists are paid for their Medicaid care.
“My worry is there will be less providers that can afford to treat the kids,” Townsend said.
Treating children helps them avoid major dental problems later, he said. Decreasing the rate could limit their access to care.
Rather than dictating the procedures dentists can do, Townsend would rather be given dollar amounts per patient.
“Then the patient and the dentist could decide on the treatment together,” he said.
Dr. Jane Gillette maintains a tiny practice caring for patients in nursing homes around the state. She is especially concerned for those most vulnerable patients, like the ones with dementia or Alzheimer’s disease.
Even though care is limited for people 21 and older, “disproportionately, the older, fragile population will feel it the most,” Gillette said.
Denying the opportunity to wear dentures is especially difficult for elderly patients in nursing homes who have fewer joys in life. Eating is one of them, and taking away their ability to eat a meal "of pot roast and cake is really inhumane,” she said.
“We should have dignity, and not having dentures takes away their human dignity,” Gillette said.
As people age, a number of factors come into play. Their mouths don’t produce as much saliva, which allows a person to rinse away germs.
Also, a lot of taste preferences go away, except for a craving for sweets. And a patient struggling with arthritis, Parkinson’s or dementia may have trouble cleaning their teeth.
“This population gets the most outrageous tooth decay you can imagine,” Gillette said. “And it’s difficult for them to go through intense dentistry.”
With the rule changes, DPHHS took away a couple of key codes dentists use to manage cavities in this population. Dentists have easy techniques to reverse cavities that don’t require shots or extractions.
Not only is it easier on patients, but the cost is much lower, Gillette said.
The alternative is for them to go the hospital and undergo dental anesthesiology while cavities are filled.
“Literally there is no more expensive way, and yet that is what the department is proposing,” Gillette said. “It’s pretty clear they never asked anybody with dental knowledge what codes should stay and what codes should go.”
Gillette said dentists in the state have had a very positive relationship with DPHHS over the years. It came as a surprise to her that dentists weren’t asked for their input.
She has been in touch with health department staff about the issues that most concern her. Her goal is to help make the rule changes less painful for patients.