Jacobus v. Department of Prevention, Assistance, Transition and Health Access

No. 2003-220 (Vt. Sup. Ct. July 29, 2004) ; Clearinghouse Number: 55824

Description

Minors’ Interceptive Orthodontic Treatment Is Covered by Medicaid’s EPSDT Program

Abstract

The Vermont Supreme Court held that Vermont must provide Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Medicaid coverage for interceptive orthodontic treatment whenever an eligible beneficiary’s conditions met the State’s listed diagnostic treatment criteria or when the evidence showed that they had conditions of equal or greater severity. Petitioners—9-year-old Medicaid-eligible girls—were denied coverage of interceptive orthodontic treatment under Medicaid’s EPSDT program. One minor had persistent pain in her teeth. The other had chronic pain in her jaw and speech difficulties. The Vermont Department of Prevention, Assistance, Transition, and Health Access denied coverage on the grounds that interceptive treatment was not “medically necessary” for either child. The Human Services Board approved coverage, but the secretary of human services reversed the board; the secretary found that state regulations required coverage of orthodontic treatment only where a child had a “handicapping malocclusion.” In consolidated appeals, petitioners argued that by limiting interceptive orthodontic coverage to the exact conditions described in the listed criteria, without conducting an individualized review of each child’s medical needs, department violated its own regulations as well as federal statutes and regulations governing the EPSDT program. Reversing the secretary’s order, the court found that the order violated the federal Medicaid Act and regulations, 42 C.F.R. § 440.230(c). Once a State offers interceptive orthodontic treatment, the court explained, it must do so equitably and may not discriminate by “diagnosis, type of illness, or condition.”

Additional Information

Attorney Information
Plaintiffs represented by Kristina I. Michelsen, Vermont Legal Aid, P.O. Box 606, Montpelier, VT 05601 (telephone number: 802.223.6377); Geoff Walsh, Vermont Legal Aid, 56 Main St., Suite B, Springfield, VT 05156 (telephone number: 802.885.5181).
Docket Date
2004-07-29 00:00:00+00:00

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