How A Child-Medicaid Law – Affects All Dentists And Patients. 

What does “at least” mean?  This Federal law is mandating State Medicaid offices to ensure that their Medicaid patients have equal or better access to care than the general population.  Read that again.   

What does “payment sufficient to” mean? This Federal law is telling states how they must accomplish this access to care and services – they must pay providers “sufficient[ly].” 

Historically, states try to evade this Federal law.  They take Federal funds for their Medicaid programs, but then don’t meet this Federal standard. 

Yes – the states are literally breaking Federal law (as explained below). 

Full Compliance With Federal Law Is Required:  (Not Just Substantial Compliance)

States (like Massachusetts) have argued in court that “substantial compliance is enough” and they do not need to “fully comply” with Medicaid Act laws—they were wrong.

Massachusetts lost that argument in a 2005 Federal District Court decision (Health Care for All vs Romney), which stated:

 
“…nothing merits or implies the use of a low standard with respect to a state Medicaid program’s fulfillment of its statutory and regulatory obligations……Accordingly, the standard to be applied in this case will be full compliance.” 

Since no state is believed to fully comply with 42 U.S.C. 1396a (30)a, enforcing every state into “full compliance” would dramatically increase Medicaid access and Medicaid rates nationwide.

But that is not where the impact stops – it also dramatically affects “non” Medicaid insurance coverage.

Why This Matters To Every Dentist – Whether Medicaid Or Non-Medicaid.

Medicaid standards profoundly influence non-Medicaid insurance standards and practices. 

Here’s how:

1. Medicaid Sets the Bar: (Defines Medical Necessity)

The Medicaid (i.e. government) standards sets the baseline for what is considered “necessary dental care” (care that patients need to maintain healthy teeth and gums).  

The government definition of “necessary” dental care is termed “medically necessary” dental care.  Do not be confused by the term “medical” in medically necessary.  All necessary dental care is “medically necessary” in the government definition – a simple tooth filling to treat a small cavity is “medically necessary” to the government.

Private dental insurers adopt these “medical necessity” Medicaid standards to establish their private standards – or they would be out of compliance with government standards. 

For this reason (as described below), private insurers such as Delta Dental of Massachusetts and DentaQuest, which simply administrate (not actually fund) Medicaid program payments in many states will often try to lower Medicaid standards – because it allows them to decrease their private-side insurance spending, indirectly saving themselves money (not just the state). 

2. Regulatory Capture: (Standardizing a lower standard of coverage)

Regulatory capture is the instance in which a regulated entity (such as a private insurer like Delta Dental of Massachusetts) captures control of the very government that regulates it – through a government-subcontractor-Medicaid-administration agreement. 

The agreement gives the insurer day-to-day ability to influence the interpretation of the Medicaid insurance regulations, and the personal relationships needed to persuade changes in the state Medicaid laws – resulting in harmful changes that create healthcare inequity (Medicaid Discrimination) for Medicaid patients. 

But the inequity does not last long, since the harmful changes are then adopted into the private insurer’s state plans – affecting non-Medicaid patients.  While the temporary inequity disappears, the impropriety is now standardized into a lower overall standard of care – that was government driven – through regulatory capture.   

In Massachusetts, between 2012 and 2024, Delta Dental of Massachusetts (DDMA) and DentaQuest were infamous for this behavior.  Their regulatory capture activity trickled down to their private insurance plans – saving them money.  In 2024, DDMA and DentaQuest lost their Medicaid Administration contract with Massachusetts due to numerous problems, including corrupt activities. 

3. Medicaid-Rate Influence:

Medicaid rates are calculated into UCR (Usual, Customary, and Reasonable) rates used by private insurers – so that even non-Medicaid insurance funding is affected by Medicaid funding standards. 

Call To Action – What We Need To Do:

All dental organizations (ADA, AGD, AAPD*, etc) must know what this article is explaining.

They should direct their state and federal advocacy funds to influence state and federal Medicaid programs – because enforcing powerful laws that already exist would be the most efficient/ effective spending of their limited advocacy funds. 

Of all the organizations, the American Dental Association (ADA) has the greatest ability to drive change, but the ADA may not be nimble enough to do this (so another leading organization should consider doing this).

Here’s what the ADA (or AGD/AAPD) should do:

1. Investigation: The ADA’s Health Policy Institute should investigate each state’s Medicaid program for compliance with 42 U.S.C. 1396a (30)a.

Simply ask every state Medicaid program to provide their required “Access Plan” to show how they comply with 42 U.S.C. 1396a (30)a. 

Similar to what was found in Massachusetts – they will find is that no state complies with the law.

2. Reporting: Produce a comprehensive report outlining non-compliance in each state.

3. Submission to CMS: Send this report to the Center for Medicare and Medicaid Services (CMS), along with the case-law identified above – requiring full compliance.

4. Legal Support: The ADA should be prepared to support states with litigation funds (if desired by the state) to legally enforce compliance by suing the State Medicaid program – if needed.

Why This Is An Easy Win:

Unlike many organized dentistry initiatives that aim to create or change laws, this powerful access law and the “full compliance” case law is already on our side.  (read that again)

We just need to enforce it.  And organized dentistry already has the staff to do the investigation and reporting. 

This is low-hanging advocacy fruit. 

How Dentists Can Help?:

The answer is simple but crucial: get involved with the ADA, AGD, AAPD, etc. 

Getting involved does not just mean “renew your membership.” 

It means:

• Recognize that The Future of Dentistry is at Stake
• Bring this Medicaid knowledge to your local, state, and national meetings.
• Influence them to take action on this Medicaid compliance issue.
• Encourage practicing (purpose-driven) dentists to push for this (and similar) advocacy.
• Stay well-informed on state and federal advocacy issues.
• Elect leaders who are advocacy-oriented. 

About The Author: 

Dr. Mouhab Rizkallah has spent decades creating dental insurance laws and changing Medicaid laws. 

He is the author/ filer of Massachusetts Question 2 (year 2022) – the first Dental Ballot in United States history – which established the nation’s first minimum Dental Loss Ratio requirement for dental insurers (and robust annual reporting requirements). 

He has successfully sued the Commonwealth of Massachusetts four times in his capacity as President of the Medicaid Orthodontists of Massachusetts Association (MOMA), leading to over 100% increases in patient coverage for orthodontics in the state of Massachusetts. 

Dr. Rizkallah is currently also the President of the AADIQ (American Alliance for Dental Insurance Quality), and has received numerous public service awards and national accolades for his dental advocacy work in dentistry and orthodontics.        

*ADA – American Dental Association; AGD – Academy of General Dentistry; AAPD – American Academy of Pediatric Dentistry