Dental Insurance Benefits

When treating a patient injured on the job (Workers’ Compensation) or in a motor vehicle accident (No-Fault), dentists must abide by the rules and regulations of the NYS Workers’ Compensation Board or the NYS Department of Financial Services, respectively. Dental claims are billed to the patient’s Workers’ Compensation or No-Fault insurance carrier. For both of these programs, dentists cannot collect fees in excess of those allowed by the NYS Workers’ Compensation Dental Fee Schedule. Both Workers’ Compensation and No-Fault share the same fee schedule.

Dentists are not compelled to treat patients injured in these types of accidents; however once they agree to do so, they are required to accept the fees established by the carrier as payment in full. The treating dentist cannot balance bill the patient for any difference between the NYS Workers’ Compensation Dental Fee Schedule and the usual office charge for the same treatment procedures. Patients cannot establish “private pay” arrangements with their dentists. If a dentist chooses not to accept the Dental Fee Schedule, the patient’s only option is to obtain care from a doctor who will.

As part of an initial examination, dentists should question patients about the source of any apparent injuries and document the source of the injuries in the patient record. Not knowing whether an injury occurred in the workplace or involved a motor vehicle accident does not exempt the doctor from Workers’ Compensation or No-Fault program requirements.

Resources:

Workers' Compensation Overview, Fee Schedule, FAQs 
Workers' Compensation On Board Claims System
No-Fault FAQs

Additional questions? Contact Jacquie Donnelly at NYSDA or 518-680-2750.

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.

Additional Resources:

NYSDOH eMedNY
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
managedcarecomplaint@health.ny.gov

Treating Patients Enrolled in Medicare Advantage Plans

When treating a patient covered by Medicare, it is important to know the rules determining whether you will be reimbursed for providing services. Medicare covers dental care only in limited circumstances. Dentists can be paid by Medicare if they perform medical services covered under Medicare Part A (hospital) or Medicare Part B (medical) as long as they have enrolled as a Medicare provider (there are different forms for Medicare enrollment so you must be sure you use the correct form). Covered services include biopsies, the extraction of teeth to prepare the jaw for radiation treatment, and an oral examination performed on an inpatient basis as part of a comprehensive exam prior to renal transplant surgery or performed in a federally qualified health center prior to a heart valve replacement.

Medicare Advantage plans (Medicare Part C) offer supplemental benefits through private insurance carriers. Supplemental benefits can include dental and vision, which are not typically covered under original Medicare. Dentists are now seeing an increase in patients who are enrolled in Medicare Advantage plans. According to the National Association of Dental Plans, 51% of Medicaid-eligible individuals are expected to enroll in a Medicare Advantage plan by 2030.

Effective January 1, 2022, providers will now be able to receive payment from Medicare when treating enrolled patients regardless as to whether they had previously filed an opt-out affidavit with a CMS Medicare Administrative Contractor (MAC)*. However, the opt-out provision is still in effect for services covered under original Medicare. Ordering and referring providers must still be enrolled in Medicare in order to receive payment for services from Medicare. 

If an opt-out affidavit was filed prior to June 16, 2015, it will automatically renew every two years. Dentists who do not want their opt-out to renew at the end of a two-year period must cancel the renewal by notifying, in writing, all MACs with which they filed an affidavit at least 30 days prior to the start of the next opt-out period. 

Dentists can determine whether they have opted-out of Medicare and when their opt-out affidavit expires at: https://data.cms.gov/Medicare-Enrollment/Opt-Out-Affidavits/7yuw-754z.

For additional information about Medicare, visit CMS.gov

* The Medicare Administrative Contractor in New York State is National Government Services.

Additional Medicare resources available on the ADA website