New York’s Medicaid program offers a wide range of services, as well as one of the highest dental fee schedules in the nation. New York covers all necessary dental treatment for both adults and children.
The New York State Department of Health (DOH) administers the Medicaid program. Enrolled patients can seek care from any dentist who is a Medicaid provider. However, over the past two decades, DOH has contracted with HMOs to enroll patients and provider networks, and process claims for services. DOH’s goal is to transition all Medicaid patients into managed care. Most HMOs contract with dental IPAs (Independent Practice Associations] for their dental benefits. Patients in an HMO can utilize their Medicaid benefits only when treated by dentists contracted with a dental IPA. These managed care companies must adhere to NYSDOH’s Medicaid policies. They can be more generous in their benefits but cannot be more restrictive.
Dentists that contract with managed care plans may not receive the same reimbursement as those in the “fee-for-service” program. Their reimbursement is based on the fee schedule and reimbursement policies agreed to contractually between each individual dentist and each managed care plan.
Medicaid only can reimburse doctors who are enrolled in the program. Enrolling does not require that dentists see all Medicaid patients; however, patients cannot be turned away based on their age, gender, religion, race, nationality, or disability.
Doctors cannot “balance bill” for Medicaid services. Patients eligible for Medicaid benefits can select any dentist that they choose and agree to reimburse the doctor for treatment services out-of-pocket if no claim is submitted to Medicaid.
NYSDA’s Legal Services Panel includes attorneys with expertise in Medicaid to assist members with participating provider contract negotiations and in responding to Medicaid-related audits. NYSDA’s Special Committee on Dental Medicaid reports members’ concerns about Medicaid to the Council on Dental Benefit Programs and the NYS Department of Health.
NYSDA’s Medicaid-related activity covers a broad range, including legislative action, direct advocacy with the Department of Health, and legal action through the courts. Annually, NYSDA lobbies to maintain funding in the State budget to ensure the continuation of both the adult and pediatric dental programs.
Enroll as a Medicaid provider
Subscribe to NYSDOH Medicaid email notifications
Questions regarding Medicaid dental policy and billing
Complaints against a Medicaid managed care company may be submitted to:
NYS Department of Health
Managed Care Complaint Unit
OHIP DHPCO 1CP-1609
Albany, NY 12237