Cushion v. Dep't of PATH
In Cushion v. Dep't of PATH, 174 Vt. 475, 807 A.2d 425, 428 (Vt. 2002), state regulations implementing the Vermont Medicaid plan covered full dentures and oral surgery but excluded coverage for partial dentures. Id. at 427. Cushion and her co-plaintiff both had established a need for partial dentures, but, pursuant to the plan's specific exclusion of partial dentures, their requests were denied. Id.
On review, the Vermont Supreme Court limited the regulatory exclusion of partial dentures to apply only to dentures that were sought uniquely for cosmetic purposes. Id. at 430. It did so because it held that once the Vermont plan offered full dentures to those with a need for them, it was required to offer partial dentures to those who could establish an equivalent need. Id. at 429.
Citing earlier cases pertaining to Medicaid coverage for services in optional categories of medical assistance, it determined that "the state's provision of dental services must 'bear a rational relationship to the underlying federal purpose of providing the service to those in greatest need of it.'" Id. at 428.
The Cushion court determined that when the regulation referred to the "purpose" for which the service was offered, it referred to the federal purpose in placing the service in the Act as opposed to the state's purpose in including the optional dental coverage within the scope of the state's Medicaid program. 807 A.2d at 428 ("In administering the Medicaid program, the state's coverage must achieve the federal purpose, not the state purpose.").
The Cushion court then attempted to ascertain the federal purpose behind including "dental services" as a category of "medical assistance" under the Act by citing the definition of "dental services." Id. at 428-29.
It concluded, without analyzing the context of the definition, that "the federal purpose, according to federal Medicaid regulations, includes the treatment of 'the teeth and associated structures of the oral cavity; and disease, injury, or impairment that may affect the oral or general health of the recipient.'" Id. (quoting 42 C.F.R. 440.100(a)(1)-(2)).