Montanans on Medicaid Face Cut to Dental Services in 2018

Proposed reduction in Medicaid services expected to go into effect in March, with a public hearing on the changes scheduled for Feb. 1

By Molly Priddy
Dr. Ken Madsen inspects Johanna Schaeffer's teeth at the Flathead Community Health Center on Jan. 26, 2015. Greg Lindstrom | Flathead Beacon

When Dr. Wendy Nickisch removes teeth from an adult patient, she doesn’t just see an extraction on her schedule.

As those teeth come out, she recognizes the effect their loss will have on the patient’s ability not only to chew, but also on social interactions and general health.

And now with the state Department of Public Health and Human Services proposing significant cuts to dental services in Montana’s Medicaid program, Nickisch, who directs the dental program at the Flathead City-County Health Department’s Community Health Center, said the quality of life for these patients is on the line.

The DPHHS has proposed a new set of administrative rules for Medicaid, eliminating dental services introduced to the program when Montana expanded Medicaid in 2015. If finalized, the rules go into effect in March; there is a Feb. 1 hearing on the rule changes in Helena.

The new rules, released Jan. 12, cut coverage for crowns, dentures and bridges for adults, and comprehensive orthodontics would only be available to people up to age 20 with specific conditions, such as deep overbites or cleft palates.

“The cuts to Medicaid would be pretty detrimental to Montanans,” Nickisch said. “Not only can’t we replace the teeth so you lose functionality, but also without the teeth, their quality of life is lost.”

Social stigmas attached to teeth and socioeconomic status could result in more challenges for a patient, such as having trouble finding a job, she said.

Preventative care is still covered, but if a tooth needs to come out for any reason, that patient will be left with a hole in their smile.

“Even when the teeth don’t need to be replaced but they need a crown to save them, sometimes we have to end up taking them out because the crowns won’t be covered,” Nickisch said.

Dental services are just one piece of the Medicaid cuts underway in Montana. Stacey Anderson of the Montana Primary Care Association said the budget trimming impacts other vulnerable populations, such as those who need targeted case management for developmental disabilities or severe mental illnesses.

Already, those services have felt the cuts, with case manager layoffs, campus closures and reduced or altered services at local organizations treating people with mental health issues and developmental disabilities.

In many cases, empty positions will stay vacant as part of cost-saving measures, Anderson said.

Montana expanded its Medicaid program in 2015, after the Affordable Care Act was ruled constitutional. In 2012, roughly 20 percent of the state’s population was uninsured, falling to 15 percent in 2015, then 7.4 percent in 2016, according to the Commissioner of Securities and Insurance.

On a federal level, Congressional Republicans have made several unsuccessful attempts to repeal the Affordable Care Act, most recently repealing the individual insurance mandate through the GOP tax bill. The changes go into effect in 2019.

Federal movement on health care affects the landscape for both Medicaid and Medicare. Lydia Hadley, senior outreach advocate and Senior Health Insurance Program counselor for Flathead County’s Agency on Aging, said there are a few changes to Medicare in 2018 when compared to last year.

For example, Medicare patients have a cap on physical therapy, limiting them to $2,010, Hadley said. Though if for some reason patients need more therapy, they can apply for additional coverage, she added.

Medicare premiums went up, with most people now paying $134.

“Basically, no one should be over $134,” Hadley said. “Some people are paying less because it goes by cost of living.”

The highest income bracket changed for Medicare in 2018; in 2017, anyone making more than $214,000 had to pay the $295 premium. This year, anyone making more than $160,000 pays the $295 premium.

Hadley said that given Medicare’s massive and often complicated nature, it can be difficult to know something has changed until it affects someone.

“A lot of times, it is hard to pinpoint exactly all changes until they come up as an issue,” Hadley said. “We definitely appreciate being able to talk with the community members and find out what they’re wondering.”

The Agency on Aging hosts a Medicare 101 class the fourth Tuesday of every month to go over questions and concerns.

“We always encourage it,” Hadley said. “Even if you’re already on Medicare, it’s not a bad idea to come and get a refresher.”

At the dental clinic, Nickisch sees about 15 patients a day, four days a week. It’s come a long way since it was housed in a bus in 2009, with the addition of a dental clinic and then an expansion into the new South Campus Building in Kalispell.

DPHHS has also proposed a 3 percent cut in Medicaid reimbursements to providers, which Nickisch said would likely have a chilling effect on private providers’ ability to take on Medicaid patients.

“Then it’s falling to the safety-net public health centers,” Nickisch said. “My clinic itself is booked out three months, so it’s really restricting access to care.”

The Flathead Community Health Center accepts most private insurance, along with Medicaid and Medicare. It also accepts patients on an income-based sliding-fee scale. In 2016, the hygienists and dentists saw 2,310 patients.

The dental chairs are full every day with people getting cleanings, fillings and extractions, but Nickisch said she and her staff also manage to squeeze in emergency-care patients.

Dental care is key to overall health, she said.

“A lot of the times people don’t realize how big of an impact the mouth has on the rest of the body,” Nickisch said.

For more information on the Flathead Community Health Center, visit www.flatheadhealth.org or call (406) 751-8101. For more information on the Flathead County Agency on Aging, visit www.flathead.mt.gov/aging or call (406) 758-5730.