Right to Know PA Medicaid Payment Rates


Pennsylvania Supreme Court Rules Medicaid Payment Records Must Be Released to Public

The Pennsylvania Supreme Court has ruled that the public has the right to scrutinize how billions of dollars in taxpayer funds flow from the Department of Human Services (DHS) to private insurance companies to operate the state’s Medicaid program. As a result of this pair of lawsuits filed by the Public Interest Law Center, DHS must release contracts showing how much Medicaid managed care organizations (MCOs) pay to dental subcontractors and certain dental providers to treat millions of low-income children, people with disabilities, and other individuals enrolled in Medicaid.

Read the decisions here:

“This is an important win for transparency and accountability, especially since Pennsylvania’s Medicaid program accounts for 30% of our Commonwealth’s General Fund budget,” said Benjamin Geffen, staff attorney for the Public Interest Law Center and lead counsel on this case. “Medicaid expenditures can no longer be hidden just because DHS has decided to contract with private insurers to deliver services.”

These decisions come in a pair of appeals filed by the Public Interest Law Center against DHS and seven insurers and subcontractors for access to contracts showing payment rates for dental services under Medicaid. Instead of directly paying dentists who treat Medicaid patients, DHS funnels taxpayer dollars through two layers of private insurance companies: managed-care organizations and dental subcontractors.

The Public Interest Law Center has been pursuing this litigation as part of an effort to understand whether low provider reimbursement rates are to blame for inadequate access to dental care for children on Medicaid in Pennsylvania. In states around the country, low Medicaid provider rates discourage doctors and dentists from accepting Medicaid, preventing children from accessing care. According to a recent report by the American Dental Association, Pennsylvania has the seventh largest dental care gap in the nation between children on Medicaid and those with private coverage: inadequate provider payment rates may be part of the problem.

The decisions also shed light on DHS’s failure to maintain appropriate records and comply with federal law. While the decision stated that contracts between MCOs and dental subcontractors must be released, the court upheld a lower court decision denying access to most contracts with dental providers, on the grounds that DHS does not possess those documents. The Public Interest Law Center is disappointed in this aspect of the decision, especially because DHS appears to have been violating federal law by not monitoring dental provider contracts to ensure that they comply with standards mandated by the federal Medicaid Act.

Although most Medicaid dental provider contracts remain inaccessible, the high court’s main decision means that medical provider contracts are subject to public release, because there are fewer middlemen between medical providers and DHS. This is the first state supreme court decision in the country granting public access to reimbursement rates for physicians under Medicaid managed care.

In addition to DHS, the five managed care organizations involved in this legal battle are Aetna Better Health, Inc., Health Partners of Philadelphia, Inc., Keystone Mercy Health Plan, UnitedHealthcare of Pennsylvania, Inc. and HealthAmerica Pennsylvania. Additional parties in one of the cases are two dental subcontractors: DentaQuest, LLC and Dental Benefit Providers, Inc.