Case: Szemerakis v. Comm, Social Services
274 Conn. 1 (2005) Medicaid
Connecticut Supreme Court
June 7, 2005
In a narrow but disappointing
decision, the Connecticut Supreme Court upheld that state’s draconian
utilization control procedures governing orthodontic treatment for
children insured under the state’s Medicaid plan.
Under Conn. Agencies Regs.
§ 17-134d-35(e), the Department of Social Services used a point
system assessment test as part of its method for determining whether
orthodontic treatment was medically necessary for Medicaid recipients
in the Early Periodic Screening Diagnosis and Treatment ("EPSDT")
program. An orthodontist determined that the child's condition warranted
eight points on the assessment test; 24 were required for eligibility
under the first prong of § 17-134d-35(e). The trial court held that
the Department had improperly established eligibility requirements
that were stricter than those authorized by the Medicaid Act. The
supreme court disagreed. 42 U.S.C.S. § 1396d(r)(3), which controlled
over the more general provision, § 1396d(r)(5), required states
to provide dental care that included relief of pain and infections,
restoration of teeth, and maintenance of dental health. Conn. Agencies
Regs. § 17-134d-35(e) was valid as a reasonable utilization control
that did not cause recipients to receive less care than was envisioned
by 42 U.S.C.S. § 1396d(r)(3). It was a reasonable attempt to objectively
balance orthodontics used for primarily aesthetic reasons and as
a medically necessary method of treating significant malocclusions.
In doing so, the court passed
on a golden opportunity to opine that the broad EPSDT mandate (providing
for coverage of "medically necessary" services) of § 1396d(r)(5)
would provide the impetus to attack the "neglected epidemic" of
untreated oral health problems for the mental and physical health
of children. Instead, the "importance of adequate oral healthcare
to all members of our society" notwithstanding, the court indicated
that the crisis presents a "complicated problem, the resolution
of which lies beyond [our] province." Fn 14 at 37. As a result,
the court reversed the trial court’s decision, and remanded the
case to the trial court for reversal and dismissal.
