Story Produced by New Hampshire Bulletin
CONCORD, NH — After years of coming close, the state is poised to give its approximately 85,000 residents on Medicaid coverage not just for tooth extractions and emergency dental care but also for the diagnostic and preventive care needed to fend off those serious problems.
The House and Senate gave final approval to Senate Bill 422 Thursday, and Gov. Chris Sununu said he’ll sign it. Advocates say it’s both a health care and workforce bill because people with obvious dental problems can struggle to get hired. Securing employment, they say, is a step toward getting off Medicaid.
“As I think about all the bills that we have year after year, most of them are so arcane. They tweak a definition or changes to eligibility for a program that already exists,” said Sen. Cindy Rosenwald, a Nashua Democrat and the bill’s prime sponsor, who began working on this issue nearly 15 years ago. “There are very few bills that have a positive, immediate impact on people’s lives. This effort will directly and positively impact and financially protect more than 100,000 Granite Staters. We don’t have many opportunities to do that.”
New Hampshire is one of fewer than a dozen states that do not cover preventative oral health care for people on Medicaid and expanded Medicaid. Two organizations have financed or found grants to provide these expanded benefits to Granite Staters, but this will be the first time that coverage is available across the state. With federal matches, the additional benefits are expected to cost the state an estimated $7.5 million or less a year.
Public support for expanded dental benefits was among the issues that dominated last year’s public hearing on the budget, but the bill providing them failed in the last days of the session. Sununu vetoed a similar bill in 2020, at the start of the pandemic, saying he supported the concept but was reluctant to take on new expenses at a time of economic uncertainty.
In a statement Thursday, Sununu said: “Expanding coverage to include dental benefits for those on Medicaid is something I have long supported, but challenged the Legislature to do so in a way where the costs are sustainable and transparent. I’m grateful for their work this session achieving those goals and look forward to signing the bill.”
Gail Brown, director of the New Hampshire Oral Health Coalition, has advocated for the benefit for years.
“After years of legislative, policymaker, advocate, and community collaboration, SB 422 is now poised to open the door to affordable, accessible dental care for New Hampshire adults covered by Medicaid and Medicaid expansion,” she said. “A dental benefit supports individual and family engagement in employment, education, and community activities.”
If the bill gets the governor’s signature, Brown said the next challenge will be recruiting enough dentists to take on Medicaid patients, given uncertain reimbursement rates and concerns about people showing up for appointments.
Under SB 422, the state would cover annual comprehensive oral examinations, x-rays or other imaging, treatment to prevent disease, topical fluoride, oral hygiene instruction, behavior management, and smoking cessation counseling. Restorative dental care, such as replacing fillings, missing or damaged teeth, crowns, and bridges would also be covered, as would oral surgery needed to relieve pain, eliminate infection, or prevent imminent tooth loss.
Access to that broad array of care is what Medicaid recipients and their families have pushed for for years. That includes Julie Hilliard of Claremont, whose adult son Cameron cannot get coverage until his dental problems become bad enough to land him in a hospital.
“What’s covered in New Hampshire is they will go in and pull the tooth out,” she told the Bulletin in November. Even then, cleanings aren’t covered, Hilliard said. One anesthesiologist proposed a solution, telling Hilliard she should have all her son’s teeth pulled and be done with it.
“He could even learn to eat steak with no teeth,” Hilliard recalls him saying.
ABLE NH, which advocates for people with disabilities, said the bill demonstrates bipartisan agreement that health equity is also fiscally prudent public policy.
“ABLE NH is very proud to have been on the team achieving this positive step forward in oral health care policy for the Granite State’s most vulnerable citizens – Medicaid recipients,” Executive Director Lisa Beaudoin said. “For the disability community, access to preventative and restorative oral health care means no longer having to use expensive emergency room care for dental infections due to untreated decay. Healthy mouths free of pain will lead to improved rates of employment for people with disabilities as well as improved overall health care outcomes.”
SB 422 calls for using nearly $21 million in settlement money, secured by the state in January against a company hired to manage Medicaid pharmacy benefits, to cover the first three years.
The new benefits would have no cap on benefits or copays for preventive services. The other dental care would be capped at $1,500 a year and require an as-yet unspecified copay for those with household incomes above 100 percent of the federal poverty level, which is $27,750 for a family of four.
Coverage for dentures would be provided only for Medicaid recipients with developmental disabilities, acquired brain disorders, and those in the Choices for Independence program, which includes the elderly and people with chronic illness or disabilities.
The expanded benefits would begin in April 2023.
Brown said the coalition would have preferred there be no copay but was pleased to see preventative services excluded from that. She called the bill acceptable, given the other coverage for which she and others have spent years advocating.
“We have to start somewhere,” Brown said.
The state’s dental community has supported legislation for expanded benefits, but dentists here and nationally have raised a number of concerns, Brown said.
They are worried about low reimbursement rates that fail to cover services, something other primary care and hospitals have long said is a problem. Appointment no-shows are another hurdle, given that this population can struggle to find transportation or experience other barriers such as having no paid time off from work.
“The target population probably doesn’t have the resources to be there 100 percent of the time,” Brown said. “This is a valid concern because an empty chair is an empty chair.”
To help with that, dentists want Medicaid to provide care management that reminds patients of their appointments and ensures they have transportation.
AmeriHealth Caritas, a Medicaid managed care organization that began working in New Hampshire in 2019, provides preventive, diagnostic, and basic restorative and periodontal care for its adult members.
Aspire Living and Learning, a nonprofit that provides treatment and supports for people with intellectual and developmental disabilities, has received $19,000 in grants from Northeast Delta Dental Foundation, Bangor Savings Bank, and Cogswell Benevolent Trust to provide comprehensive dental care to the adults on Medicaid it serves.
John Whittemore, senior director of program operations, said Aspire Living and Learning has been able to assist 11 people for their 18 appointments. The nonprofit pays providers directly and provides its clients transportation to appointments.
“These grants have given the people we serve access to dental care that they would not have had access to through Medicaid, including preventative care,” Whittemore said.