Utah's Medicaid program may be forced to ratchet up its payments to dentists if a federal agency decides pregnant women and children's access to care is threatened.
Under the Social Security Act, Medicaid payments have to be high enough to draw in providers and give beneficiaries the same access to care as the general public.
But last session, state lawmakers -- strapped for cash after revenue plunged -- erased the one-time 24 percent jump in pay that dentists received in 2008, on top of rolling back their 4.5 percent cost of living raise.
The move prompted an outpouring of protest from dentists, who say they can't keep seeing Medicaid patients at such a reduced rate and keep their practices afloat.
"We feel a moral obligation to treat (children), but the state doesn't feel that way," said Jason Horgesheimer, president of the Utah Academy of Pediatric Dentistry. "We're providing all of this charity care and we just can't continue doing it and maintain a small, viable business."
Now the Centers for Medicare and Medicaid Services (CMS) is reviewing Utah's state plan amendment, which it must file when it changes its payment rates. A spokesman for the federal agency said it's concerned the only two groups still eligible for dental coverage in Utah -- pregnant women and children -- could be unable to receive the care they need.
"There are regulations about access," Mike Fierberg said. "We're not sure (Utah is) running afoul of it or not. We're still working with the state on trying to come up with a state plan amendment, or SPA, and the discussions are still ongoing."
If CMS finds Utah's payments to dentists are too low, it could require the state to retroactively reinstate its original rate, requiring Medicaid to reprocess every claim filed since May 25, said state Medicaid Director Michael Hales. Or CMS may negotiate a different rate.
It's a move that could cost the program hundreds of thousands of dollars -- an expense the Legislature would have to foot in addition to the $17 million in supplemental funding Medicaid will ask for this session. That money is sought to fund its skyrocketing caseload through the end of the fiscal year.
Absent an infusion of money, Hales said, Medicaid could be faced with slashing optional services or reducing other providers' reimbursement rates.
In a joint letter sent to the Utah Legislature earlier this year, 53 dentists warned action to boost their reimbursement -- restoring about $2 million to Medicaid, which would bring in three times as many federal matching dollars -- can't wait.
"The entire network of Medicaid providers will be gone, and at an extreme financial cost to the state," the letter stated. "More importantly, families will not have access to care and many children will suffer from untreated dental [cavities], abscesses and basic preventive measures, which will greatly increase overall cost of treatment."
The rate reduction, along with the elimination of dental services for Medicaid's non-pregnant adult population, has prompted 14 dentists to withdraw as providers, the state reported to CMS.
But many more are threatening to do so.
Horgesheimer said a recent survey found just two of Utah's 57 practicing pediatric dentists will continue to see Medicaid patients after Jan. 1 if their rates don't increase. That information has been shared with both Medicaid and CMS.
"They see there is going to be a major crisis when we're essentially getting 30 cents on the dollar," he said.
CMS has asked the state to gather additional information on the impact the cut has had on providers, which it submitted two weeks ago.
In its correspondence with the federal agency, Utah's Medicaid pointed out that, when the 24 percent increase was in place for care provided to pregnant women and children, dentists were only making 7 percent less than what they were paid to treat non-pregnant adults.
Although that increase is now gone, about 40,000 non-pregnant adults are no longer eligible for dental services. So the Utah Department of Health's five family dental clinics, as well as the state's federally qualified health centers, are able to absorb more of the remaining eligible Medicaid patients who can't get in to see private providers, the state asserts.
"Medicaid is cognizant that no provider would like to have their reimbursements decreased," Hales wrote in a letter to Richard Allen, CMS' regional administrator. "However, there does not appear to be an access issue at this time."
Horgesheimer doesn't buy it. The clinics are overrun. And they don't have pediatric dentists who are equipped to safely sedate children who would not otherwise tolerate treatment.
"It's going to cost Medicaid so much more for treating these kids in an emergency situation in the hospital," he said.
Reduced access to health care triggering lawsuits
With the economy in the doldrums, many states are grappling with the costs of Medicaid reimbursement to providers.
Some, including California, Idaho and most recently, Michigan, have been targeted by class action lawsuits claiming they've violated federal Medicaid laws and created an access problem for their most vulnerable populations.
Lincoln Nehring, Medicaid policy director for the Utah Healthy Policy Project, said it's an option groups here are exploring, though it might be more difficult in Utah than in other states to take legal action. Private litigants' ability to claim a violation of federal rights under Medicaid's equal access statute is the subject of evolving judicial philosophy.
One federal appeals court -- the Ninth Circuit, to which California belongs -- decided providers have legal standing to sue; the 10th Circuit, however, which includes Utah, is silent on the matter.
"There is some question about whether that law grants individual right of action and the circuits are divided," Nehring said. For groups contemplating a legal action, "it's an unknown. There's that risk you'd put all this time, effort and money into suing and the court would say you don't have standing."