The Corner Penthouse

One of the problems with having a low income (read: poor) is that you are not afforded the luxury of having the best medical care, especially when it comes to dental. It's a problem that I have had to deal with for the past 30 to 35 years, and it just got worse. Read on to find out more...

Before I get into my current dental dilemma, I need to give the detailed backstory of how I got here and what I have had to endure. Let's set the Wayback Machine to the mid-1990s, around the time when I turned 18. From this point onward, I have had to rely on state-provided Medicaid insurance in order to pay my medical expenses as my income was (and still is) very low, and I never had any medical or dental insurance provided by an employer. Bear in mind that in the United States, the government doesn't mandate that all medical providers accept government-provided insurance as a requirement of obtaining a medical license. It should, but it doesn't. As such, most dentists do not want to accept Medicaid insurance because the U.S. government is, apparently, too slow to pay the dentists for the work that is billed.

So, the usual routine would be that I'd go through a list of dentists in walking distance, I'd cold call them and ask if they accepted Medicaid, and would go to the closest one that said "yes". Then, after a few years, the dentist would drop Medicaid - usually only telling me a day or two before my scheduled appointment - and I would have to find a dentist again. If the dentists actually cared about their patients, and not profits, they would accept the insurance for their existing patients, and just stop accepting new Medicaid patients. Of course, they put profits before patients. Is that a surprise? Anyway, I don't have a clear history of how many dentists I visited between 1995 and 2012, but I'm thinking it was at least a dozen.

Cut to December 2012, and I'm now living in a new town due to Hurricane Sandy destroying my home of 23 years. I previously wrote about this portion of my dental woes back in June of 2021, but I'll repeat myself in order to keep the whole tale of woe in one place. As I was saying... I didn't want to take public transportation to my old town, and then walk a rather healthy distance, to the dentist that I was seeing before the move. So, I drew up a list of dentists in my new town, cold called them, and went to the closest one who accepted Medicaid. That would be Luxury Dental, which used to be located on Rockaway Avenue in Valley Stream, NY. I went there a few times, but did not care for the way I was treated by the Russian-trainees who did the work. Since they were not the only dental office in the town that accepted Medicaid, I had an option to go elsewhere.

I believe that the next dentist in Valley Stream that I went to was Issac Perlman (41 West Merrick Road, 516-872-2168). All was good at first, though he kept wanting to remove perfectly good filings just so he could make money from my insurance from doing new ones. Even worse, he caused one of my teeth to get infected, and then laughed it off and tried to act like he wasn't responsible. Seriously, if I had the money, I would have sued him for medical malpractice. DO NOT EVER GO TO DR. ISAAC PEARLMAN DDS IN VALLEY STREAM, NEW YORK!!! I can not emphasize this enough. Having had to endure two shitty dentists in Valley Stream, I decided that it would be worth the effort to use public transportation to go back to my pre-hurricane dentist. As it turns out, sometime between December 2012 and early/mid 2016, the Great Expressions dental office moved, so there was no longer a long walk after getting off the train in my old town.

The Great Expressions dental office in East Rockaway, NY (at 112 Main Street, 516-210-6084), was great! The dentist and hygienists did quality work, and thanks to a relative of mine who was willing to pay for a root canal and gas (which Medicaid wouldn't cover), the dentist was able to save the infected tooth and turn it into a crown. Generally speaking, I require the nitrous oxide gas in order to get fillings and other dental work done because of other medical ailments I have. This has become more of an issue over the past few years, as my tolerance for having work done without it has diminished.

Anyway, as expected, after a year or two, Great Expressions dropped Medicaid. Like usual, they only informed me a day or two before my scheduled appointment - and after I already received a call from another receptionist there confirming that appointment! So, back to Valley Stream, where I pulled Central Avenue Dental (125 North Central Avenue [formerly at 139 North Central Avenue], 516-887-0020) from the previously-compiled list. I started going here in 2017. Generally, things were okay. I do remember having to get a tooth filled on one visit, and since they didn't offer the gas, I had issues mid-way through the procedure, prompting the dentist to have to stop for a bit, and then hurry and finish the job before I had another issue. I continued going to Central Avenue Dental until 2021, when a few days before my scheduled appointment in June, they called me and said that they no longer accepted Medicaid. I am SOOOOOO tired of this broken record playing in my life.

So, now it's June 2021, and every one of the dentists in Valley Stream who previously told me that they accepted Medicaid no longer does. With no available dentists in walking distance, and I was forced to do another town-wide search; only this time for the next town over that I could take a train to. I ended up settling for Luxury Dental, who at this point had moved from Valley Stream to Lynbrook (at 393 Sunrise Highway, 516-825-6969). Yes, the same Luxury Dental that I had originally seen in Valley Stream who didn't treat me very well. I'm not saying that I wanted to go there, but I wasn't left with many options since, even in Lynbrook, many dentists did not accept Medicaid.

I went there two or three times in the Summer of 2021, and they found a cavity that needed to be filled. They tried to do the filling, but I started to gag as soon as the dentist put a small piece of paper in my mouth. Since Luxury Dental did not offer gas, and I could not have the work done without it, the cavity remained. At this point, depression set in, and I went without a dentist, and with a cavity that needed to be filled, for over a year.

On a lark, I decided to see what would happen if I wrote a letter explaining my dental situation to New York Governor Kathy Hochul and President Joe Biden. Would these politicians, who are supposed to be working for me (an American citizen), actually care and pull some strings to get me the special help I need? Of course not! I never, for a minute, thought they would. Hochul's office sent a letter confirming receipt of my letter, and that was it. Biden's office put me in touch with someone who handles HOUSING help! I don't know if I should find that kind of misdirect humorous or insulting.

Jump to September 2022 and I decided that a new course of action needed to take place. If no local dentists would accept Medicaid, perhaps it was time that I signed up for one of those Dual Eligible Special Needs Plans (D-SNPs) for individuals who have both Medicare and Medicaid. I see them advertised all the time on TV, usually targeting senior citizens who watch the channels that air vintage programming. I figured that if I had a plan under a big-name insurance company, it would be easier to find a local dentist that accepted it. Well, I thought right... and wrong!

On October 1, 2022, I officially became an Aetna member, and received a member card like the redacted one pictured below. I was enrolled in the Aetna Medicare Assure Plan, which gave me Aetna "Medicare HMO" and "Aetna Medicare Dental", which the back of the card states "is part of Aetna Dental PPO Network". When I signed up, I had no idea that medical and dental were separate insurance plans. I didn't know at the time that that would be a HUGE problem later on.


Now that I had "new insurance", I went through the motions I had gone through SOOOOO many times before: compile a list of local dentists, call them all up, ask if they accept Aetna. I found one that was super close, Henner Dental Associates (247 Rockaway Avenue, 516-825-2320), whom I visited for the first time in November 2022. I was quite pleased with the work done by Dr. Henner and the staff. I never had a better experience getting my teeth cleaned, and Henner properly administered the nitrous oxide gas while filling all of the cavities I had for over a year, so the whole procedure went quite smoothly. Henner's office said that they accept Aetna PPO, and since the back of my card said that "this plan is part of Aetna Dental PPO Network", it was assumed by all that Aetna would pay them. I do wish they would have confirmed that with Aetna first, instead of having a "we'll see" attitude (an exact quote from the dentist regarding the billing), as I would find out a month later that Aetna would NOT initially pay for the work that was done there. Aetna's reason: Dr. Henner isn't in Aetna's PPO Network.

This is where I would learn all about the new world of dental bullshit I now had to endure as an Aetna member. Silly me, thinking that all of my dental worries would be a thing of the past when I moved from Medicaid to big-name Aetna. Okay, try to wrap your mind around this: Although my "Aetna Medicare Dental" plan "is part of Aetna Dental PPO Network", it is NOT a PPO plan. However, it will pay any dentist who IS a part of the Aetna PPO Network. If the dentist is not a part of that network, Aetna won't pay. Confused?

Of course, it fell upon me to do the work to get Aetna to pay Henner by filing an appeal of the rejected claim. Henner's office, supposedly, did an appeal, as well. I have to assume they did, as I never saw anything from them to prove it. I just knew that I had to get ahead of this matter, lest Henner send me a $1,000 bill that I could not - and should not - pay. Quoted below are my personal notes of everything that happened over a period of three months to get this matter settled. Remember, I signed up with Aetna in order to have LESS dental worries :-)

12/7/2022 - Submitted online appeal of denied Dr. Henner claims.
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12/9/2022 - Mailed physical appeal form of denied Dr. Henner claim.
* Also give a copy on the same day to Dr. Henner's office.
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12/23/2022 - Mailed a letter to Aetna's corporate office.
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1/5/2023 at 3:40 p.m. - After speaking on the phone to Nurse Care Manager Shelly-Ann Deming, she transferred me to low-level Aetna rep Vanessa.

I told her the situation. She saw the Dr. Hennner claims on 11/8 and 11/15. I told her that I submitted appeals online and through the mail in December, and that Dr. Henner's office has been fighting it on his end. Vanessa took a look at the appeal, which she said was sent in on December 8th. It's still in process and should be closed on 2/5/2023 or earlier. They generally take 30 to 60 days to take care of it.

She put me on hold while she spoke to her manager to see if I can still see Dr. Henner with Aetna paying for it. I don't know what they discussed. She looked through my EOC (Evidence of Coverage). Vanessa sees that my ID card says that it's a PPO Dental plan, yet in Aetna's computers it said to my plan is "Total EPO Manatory".

I asked her how my dental plan can be both PPO and EPO. Vanessa did not know!!! PPO means I can see any dentist (there is no network on a PPO plan), yet she said to my plan requires me to see dentists in the Aetna network.

I said that I need to speak to someone higher up to deal with this. Of course, instead of transferring me to someone with a full name, job title, and direct phone number, she offered to FILE A GRIEVANCE for me. As she was typing (I don't know what she wrote in the grievance), I add *MY* grievances: Aetna put me in the same situation I have been in for the past year and a half where I DON'T HAVE A DENTIST! I signed up for Aetna specifically so I could have a dentist in my area that offered Nitrous Oxide gas who accept my insurance, and that's the one thing that Aetna is refusing to pay for! I can't even change my insurance until the end of 2023 (before December 7th), so I'm stuck with Aetna for all of 2023, which means that I HAVE NO DENTIST FOR ALL OF 2023.

Vanessa said that the grievance form asks what emotion I'm feeling about this matter. I said, "ANGRY, ANNOYED, PISSED OFF" that I joined Aetna for dental, and I don't have dental. Vanessa will send in this grievance. She asked what time is good for them to call me about this, and if it's okay for them to leave a voicemail message. I said, "Afternoon" and that it's okay to leave a message.
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1/17/2023 - Received the letter in mail confirming receipt of the grievance, signed by "Parvati" from the "Medicare Complaint Team". The grievance case number is G23010912203.
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1/24/2023 - Sent e-mail to Aetna execs: ExecutiveResponseTeam@aetna.com, Dan Finke (FinkeD@aetna.com), Karen S. Lynch (Karen.Lynch@CVSHealth.com). Included lots of documents attached to the e-mail and my e-mail signature with links.
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2/1/2023 - Checked Aetna's website and the 11/8/2022 dental work (cleaning) was APPROVED. The original denial was reversed. The revised claim now says "Network Status: In-Network" for Dr. Henner. This sets a precedent for all future dental work, as Aetna can no longer claim that Dr. Henner is not in the network. The 11/15/2022 dental work is still listed as "denied".
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2/6/2023 - After two weeks without a reply, I resent e-mail to Aetna execs ExecutiveResponseTeam@aetna.com, Dan Finke (FinkeD@aetna.com), Karen S. Lynch (Karen.Lynch@CVSHealth.com), but with an updated introduction to mention the first claim now being approved, but the second one still listed as denied. Did not attach any documents or even include my e-mail signature with links.
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2/7/2023 - Received reply to my e-mail from Seheli Kelsey (Sr. Coordinator, Complaint and Appeals Ops, Executive Response Team) telling me that "an executive analyst will review your email and reach out to you directly with their findings."
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2/8/2023 - Checked Aetna's website and the 11/15/2022 dental work (fillings) was APPROVED. It took three months, but Aetna finally paid for ALL of the dental work. Now BOTH of the original denials have been reversed, and BOTH revised claims now say "Network Status: In-Network" for Dr. Henner. This sets a precedent for all future dental work, as Aetna can no longer claim that Dr. Henner is not in the network. Hopefully, future dental work will be automatically approved and paid promptly.
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2/10/2023 - Received letter (dated 2/4/2023) from Laurie (Complaint Analyst, Medicare Complaint Team) regarding the grievance that was filed for me over the phone on January 5th. Laurie's phone number is 959-230-2684, though the coordinator working on my grievance is Alexis (959-230-8302). They extended the time frame for making a decision on my grievance until February 18, 2023 because they are "still researching [my] concerns and are currently waiting on a response from the claims department".
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2/13/2023 - Received letter (dated 2/3/2023) from "Appeal Analyst" Barry Gale (Medicare Appeals Coordinator, Medicare Medical Appeals Team) stating that my appeal of both denied dental claims was APPROVED! Aetna paid Dr. Henner on 2/3/2023 the $990.00 for the work on done on 11/8 and 11/15. The Appeal Case Number is A22343140635 and 866-397-1211 is listed as Barry's phone number (Mon-Fri 8am-5pm ET). (NOTE: The phone number given is the "Appeals Confidential Voice Mail Line" It is an answering machine and NOT a live person.)
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2/22/2023 - A day after I sent another e-mail reply to the Executive Response Team, this time voicing my displeasure at not hearing back from them after two weeks, I received a lengthy e-mail from Marilyn Gaughan (Analyst Executive Resolution, Enterprise Resolution Team) (MedicareExecutiveResponse@aetna.com, 904-351-3675). Notably, she stated that my "appeal overturned the two claim denials as a one-time exception as pay and educate". Meaning, that they won't pay for future dental work from Dr. Henner, even though his status on both claims has now been changed to "In Network", which means they can't continue to claim that he's "not in network". Nowhere in the e-mail did she address the fact that my Aetna ID card states that my "plan is part of Aetna Dental PPO Network". (Everyone at Aetna ignores this fact.)
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2/23/2023 - Received reply from Marilyn Gaughan to my reply from yesterday. She contacted two of the nearby dentists: Kenneth Berger & The Smilist. The former told her that they DO accept my insurance, which is different from what they told me in person on Oct. 31, 2022. The latter told her that they DO offer Nitrous Oxide Gas, which is different from what they told me over the phone on Oct. 31, 2022. Marilyn said to speak to Shawana at Kenneth Berger's office, or Lily at The Smilist and they will be happy to assist me.
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3/3/2023 - Received seven-page letter in the mail from Marilyn Gaughan detailing all of their findings, most of which she already told me via e-mail. It did state that Dr. Henner's network status was updated to "In Network" *only* for the sake of paying this claim, and that they still consider him to be out-of-network. It also re-confirmed that they paid Dr. Henner one-time-only, and will NOT pay him again in the future.

The one good thing to come out of this three-month ordeal, during which time I did not have a dentist, was that it gave me a high-level contact at Aetna whom I could contact in case I had any future troubles: Marilyn Gaughan (MedicareExecutiveResponse@aetna.com). No longer would I have to deal with low-level phone reps who do not have the position or power to actually help me.

Marilyn helped me find my next dentist, Kenneth D. Berger & Associates (27 East Hawthorne Avenue, 516-825-9500), who was located around the corner from Henner's office. I can honestly say that BERGER & ASSOCIATES IS THE MOST UNPROFESSIONAL DENTAL OFFICE I have ever visited. I went there in March 2023 for a cleaning, which was the worst I have ever had. I can't recall another cleaning where my gums were poked and jabbed so much in my life. That wasn't the worst, or unprofessional, part. After the torturous cleaning was done, as I was checking out, the front desk receptionist told me that they did not accept Aetna. Yes, THEY WAITED UNTIL AFTER THE WORK WAS DONE TO TELL ME THAT THEY DID NOT ACCEPT MY INSURANCE!!! Unprofessional, especially after confirming to an Aetna employee (Marilyn) that they accepted Aetna.

So, I got on the horn with Marilyn and told her what Berger's office was doing. She assured me that since she was the one who recommended them to me, she would personally file the appeal once Berger's office submitted the charge to Aetna. Thankfully, she was true to her word, and I never had to worry about that bill. I still had to worry about finding yet another dentist; my THIRD since joining Aetna six months ago!

The other dentist Marilyn had called, who claimed to accept Aetna and provide nitrous oxide gas, was The Smilist (17 West Merrick Road, 516-825-6695). Weirdly, when I called them six months earlier, they had told me that they didn't offer gas. I guess they bought a nitrous oxide gas machine sometime in the past six months. I visited The Smilist for the first time on March 21, 2023. The receptionists at the front desk were anything but helpful in the first few times I went there, making wild claims that they didn't accept my insurance. I had to inform them - as I had become an expert in my Aetna dental insurance at this point - that as long as they're in the Aetna PPO Network, Aetna will pay them. Sure enough, Aetna paid them for every single visit and service provided, even if the receptionists were still making claims that they don't accept my insurance!

For the most part, I have been satisfied with the work provided by the hygienists and dentists at The Smilist. My only real complaint is that they clearly don't know how to administer nitrous oxide gas properly; possibly because the machine was a recent addition to their office. When Dr. Jiffry Kolonda filled the first cavity shortly after that first visit, I was not sufficiently "knocked out". Thankfully, the cavity was an exterior one, so it wasn't too bad. Six months later, when Dr. Kolonda found another cavity, he administered the Novocaine in such a way that my right nostril was completely numb, rendering the nitrous oxide gas completely ineffective. That one was tough to get through.

There were no issues at all with my two visits to The Smilist in 2024; the first in March for a cleaning and x-rays, and the second in September for a cleaning. So, my intent was to continue going there. Aetna doesn't want that. For the first time in my life, it isn't my dentist that is dropping my insurance, but my insurance that is dropping my dentist!!!

On November 18, 2024, I received my new Aetna member card for 2025. I took a look at it (redacted copy below) and the only change on it was that the dental insurance was now listed as "Liberty Dental". WHAT THE FUCK!!! I signed up with Aetna to have Aetna for dental. If I wanted Liberty for dental, I would have signed up with Liberty. Furthermore, Aetna never properly informed me that it was changing my dental plan - the one thing I signed up with Aetna for, which has already been quite a headache for me (as I already detailed).


I was positive that The Smilist would not accept Liberty, and sure enough, The Smilist is NOT listed on Liberty's provider site. I have no doubt that the Aetna execs who had the brilliant idea to change their members dental insurance KNEW that by doing so, their members would have to find new dentists. Not that they care. Like the rest of the American Healthcare System, they put profits before patients/people. It is cheaper for Aetna to off-load the dental service to the no-name Liberty Dental Plan instead of managing it themselves.

Just as insulting is that Aetna did not send out any high-profile mailings specific to this dental plan change. You know, something with large, colorful text flanked by photos and clip art illustrations that would bring this FUCKING HUGE IMPORTANT CHANGE to everyone's attention. Remember, these D-SNP plans are targeted towards senior citizens, as evident by all of the photos of old folks in the quarterly newsletters I get; which also did not mention this change. Most members of the target audience are NOT going to notice this small change on the member card. Nor will they notice the brief, nearly hidden mention of the plan change in the "Annual Notice of Changes for 2025", a 20-page black-and-white all-text generic-looking book that was mailed out to members a month or two ago. The change is mentioned half-way through the book on Page 8, and as seen in the image below, is easy to miss. I sure didn't notice that it now says "Liberty Dental", and if a member didn't even look at this book and just tossed it aside when it was mailed to them, they definitely wouldn't have known about this FUCKING HUGE IMPORTANT CHANGE. Have I made it clear that this is not a change that should be buried in a mound of text?


On Monday November 18th, I fired off an e-mail to Marilyn to get more details on the matter. Since she helped me with the dental issues last year, I was hoping that she would be able to help me here. She confirmed that, yes, I would be switched over to Liberty if I don't choose another insurance company by December 7th, which is less than three weeks from the date that I received the new member card. As I write this article now, I have only THREE DAYS in which to change insurance companies, if I chose to go that route. (The "Annual Open Enrollment" period started on October 15th, but I didn't know about the dental plan change until a month later, so that was time lost.) More time was lost due to the Thanksgiving holiday - Marilyn took off the entirety of last week for it - and that she didn't reply to my Monday November 18th e-mail until Friday November 22nd. Her e-mail on that day gave me false promise that I would not have to switch dentists:

Date: Fri, Nov 22, 2024 at 12:09 PM
Subject: Re: [EXTERNAL] Aetna Dental Plan
From: Medicare Executive Response (MedicareExecutiveResponse@aetna.com)

Hello Mr. Rudoff,

I have great news!

I just received confirmation from Liberty Dental that since you are in a Dual Special Needs Plan (D-SNP), for the 2025 plan year you may continue to go to The Smilist Dental office located at 17 West Merrick Road, Valley Stream, NY 11580.

You may now rest assure you do not have to change dental providers or insurance plans for your dental coverage in 2025.

Thank you for allowing me to assist you.

Sincerely,
Marilyn

Marilyn | Analyst Executive Resolution, Enterprise Resolution Team
p 904-351-3675 | f 860-754-2010
P.O. Box 818048, Cleveland, OH 44181-8048

Instead of contacting The Smilist, Marilyn went through Liberty to find out. What had me confused was the phrasing, since Marilyn didn't specifically state that The Smilist accepted Liberty; just that I could continue to go there. Marilyn's e-mail also conflicted with the information that the front desk receptionists at The Smilist gave me when I visited the office on November 20th to find out what insurances they accept. The image below is the list they photocopied for me. As you can see, Liberty is not on the list.


After getting Marilyn's positive e-mail a few days later on November 22nd, I sent her an e-mail reply to get clarification, with a copy of The Smilist's insurance list attached. Since she took the entire following week off for Thanksgiving, she did not read my reply until Monday December 2nd. At this point, she sent a follow-up e-mail to Liberty to find out if The Smilist accepts Liberty or not. Two days would pass (more wasted time) before I would get confirmation of what I already knew would be the case:

I have reach out and have been advised by our dental Provider Network Management that oversees the Northeastern providers for Liberty Dental that as of right now, The Smilist Dental will not be in-network in 2025.

Our Provider Network stated when they advised us previously that Mr. Rudoff could continue to see The Smilist Dental office due to being enrolled into a Dual Special Needs Plan (DSNP) it was because he also has Medicaid benefits to pick up what is not paid through his Aetna plan. However, I have spoken to The Smilist Dental office on 17 W Merrick Road, and they advised me they do accept, or bill Medicaid and they also confirmed they are not in-network with Liberty Dental.

At this point, Marilyn is calling dentists in walking distance to find ones that accept Liberty and can provide the nitrous oxide gas. Unfortunately, it doesn't look likely that one will be found. Adding to the problem is that all of Aetna's D-SNP plans for 2025 will use Liberty for dental, so I can't just change plans within Aetna. This problem didn't have to be one if the Aetna execs wouldn't have put profits before people.

At this point, I'm leaning more and more towards finding a new insurance company, especially since that "Annual Notice of Change" document also shows negative changes made to the Extra Benefits Card (being reduced by $50 so that a "$50 bonus" can be given to other members) and the number of podiatry visits per year (from 12 down to 4). So, I have a mere three days to see which companies The Smilist and all of my other doctors accept, research their D-SNP plans, and sign-up with them. Actually, less than three days, as I will be busy all day on the 7th and the entire evening on the 6th.

I realize that there are others who have been screwed over by the American Healthcare System even more severely than I have. I'm not comparing my situation to theirs. I'm just getting my story out there so it can be heard with all of the others. Sadly, as long as the rich corporations continue to run this country, by having the politicians work for them, and not for the people they're supposed to be working for, nothing will change.

[UPDATE - 12/5/2024]
Given all of the dental hassles I have had in the two years since I signed up with Aetna, especially considering that dental was the very reason I even signed up for Aetna in the first place, having to change my dentist simply because Aetna wanted to save money by offloading the dental plan to a no-name company was the last straw. Today I signed up with a new insurance company, with the new medical and dental plan going into effect on January 1, 2025. Goodbye, Aetna. I sure won't miss you.