Medicare Penalty Case Highlights the Regulatory Reality of Long-Term Care: Lessons for Elder Care and Government Oversight

A recent federal court decision in New York offers a clear window into how Medicare actually operates, not as a traditional health care system that delivers services to seniors, but as a vast federal regulatory regime that happens to pay for care. The case, NCRNC, LLC v. Kennedy (N.D.N.Y. Jan. 20, 2026), involved a Medicare-participating nursing home fighting a civil monetary penalty imposed by the Centers for Medicare & Medicaid Services (CMS). The facility asked a federal district court for a jury trial under the Seventh Amendment. The court said no, and in doing so, handed elder-care providers, families, and advocates a blunt reminder of where real power lies in long-term care.The Case at a GlanceThe nursing home received a penalty for alleged noncompliance with federal participation requirements. Rather than go through the agency’s administrative process, it sued in district court seeking to block collection and arguing it was constitutionally entitled to a jury. The court dismissed the complaint for lack of subject-matter jurisdiction and rejected the Seventh Amendment claim outright.
Applying the public-rights doctrine, the judge explained that there is no common-law counterpart to a government-imposed monetary penalty tied to conditions for receiving public funds. Medicare participation is a regulated privilege, not a contractual right. Because the dispute arises from the government’s oversight of its own spending program, traditional courtroom protections, including the right to a jury, do not apply. Instead, challenges must travel the statutory administrative channel: administrative law judge, Departmental Appeals Board, and then directly to the U.S. Court of Appeals.The Real Lesson for Elder CareThis ruling is not just a procedural footnote for nursing-home operators. It reveals the fundamental architecture of Medicare’s relationship with long-term care providers, and, by extension, with the frail elders who depend on them:

• Government oversight is deliberately administrative-first and one-sided.

CMS and state survey agencies can issue penalties, threaten program termination, or suspend operations with limited immediate judicial oversight. The system is engineered for speed and control: the regulator acts, the provider defends later, and even that defense occurs inside the agency’s own framework.

• Facilities operate under a regulatory “license,” not a consumer-service contract.

Accepting Medicare (and intertwined Medicaid) dollars means stepping into a legal regime where the government sets the rules, enforces them, and largely decides disputes. Traditional due-process protections that Americans expect in ordinary lawsuits, such as full discovery, independent fact-finders, and jury trials, are stripped away in favor of administrative efficiency and taxpayer protection.

• Residents bear the downstream consequences.

When a facility faces heavy monetary pressure, the ripple effects are felt at the bedside. Staffing may be trimmed, capital improvements delayed, or non-mandated services cut. Families rarely see the survey deficiencies or penalty notices, yet they live with the impact on quality of care and the ability of loved ones to age in place safely and with dignity.

In short, NCRNC confirms what many in elder law have observed for years:  Medicare is first and foremost a legal and regulatory system that governs health care, not a health care system that confers robust rights and privileges to participants. A true consumer-oriented health care system would treat providers and beneficiaries as rights-bearing parties in a service relationship. Medicare treats them as regulated entities subject to conditions the government can enforce with broad discretion and narrow procedural safeguards.

Why This Matters for Families and Aging-in-Place AdvocatesSeniors and their families often assume that Medicare and Medicaid function like private insurance — that if care is needed, the system will deliver it fairly and that participants have meaningful recourse when things go wrong. This case shatters that assumption. It shows that the rights of both facilities and the residents they serve are limited to what Congress and the agencies choose to grant, and those rights are deliberately narrow.
For elder-law attorneys and aging-in-place advocates, the takeaway is practical:

• Proactive compliance and documentation are essential. Facilities must treat every survey as a high-stakes regulatory proceeding, not merely a clinical review. Thorough records, immediate corrective-action plans, and early legal involvement can make a difference in the administrative process.
• Families should monitor quality indicators closely. When penalties or deficiencies surface, they often signal potential changes in staffing or services. Working with long-term care ombudsmen, reviewing public quality data, and having contingency placement plans can help protect aging loved ones.
• Expect limited judicial relief. Direct lawsuits in district court are almost always dismissed in favor of the administrative channel. Constitutional arguments, while sometimes useful for leverage or legislative advocacy, rarely succeed at the trial level in this context.

The Bottom LineNCRNC, LLC v. Kennedy is a textbook illustration of how Medicare’s enforcement machinery prioritizes regulatory control over traditional legal protections. For those invested in high-quality elder care, the decision underscores a hard truth: the best safeguards for aging in place often lie outside the courtroom — in careful facility selection, advance planning, vigilant family oversight, and advocacy within the system as it actually exists.
We will continue tracking these regulatory developments because they directly shape the daily reality of long-term care. In the meantime, if you or a loved one relies on Medicare- or Medicaid-funded nursing-home care, the clearest protection remains early, informed planning with an elder-law attorney who understands both the clinical needs and the regulatory minefield. The system may be legal first and health-care second — but knowing that reality is the first step toward navigating it successfully.

Why Medicare Must Add Dental Coverage: A Lifeline for Oral Health in Nursing Homes

As our population ages, ensuring comprehensive health coverage isn't just a policy debate; it's a matter of dignity, independence, and quality of life. For the 1.2 million Americans residing in nursing facilities, poor oral health is a silent epidemic that exacerbates chronic conditions, leads to painful complications, and widens disparities among vulnerable groups. A new issue brief from Justice in Aging, released this month, spotlights a straightforward solution: expanding Medicare to include dental benefits. Titled "Expanding Medicare to Include Dental: A Path to Better Oral Health in Nursing Facilities," this report—authored by Senior Policy Advocate Samantha Morales—lays out the stark realities and actionable paths forward. As elder law professionals and advocates for aging in place, we can't ignore this call to action. Let's dive into why this matters and what it means for our clients.

The Gaping Hole in Medicare's CoverageMedicare, the lifeline for most adults over 65 and many younger people with disabilities, explicitly excludes routine dental services under Original Medicare (also known as Traditional Medicare fee-for-service). This leaves millions without coverage for cleanings, fillings, or dentures—essentials that prevent far costlier health crises down the line.
Recent tweaks by the Centers for Medicare & Medicaid Services (CMS) have carved out narrow exceptions. Since 2022, Medicare has covered "medically necessary" dental services when they are tied to other covered treatments, such as pre-transplant exams or dental care before chemotherapy for head and neck cancer. In 2023, this expanded to dialysis for end-stage renal disease. Medicare Advantage plans must match these, but supplemental dental benefits in those plans vary wildly by provider.
For nursing home residents, these piecemeal changes fall short. Trapped by mobility issues, cognitive impairments, or facility logistics, they can't easily chase off-site care. The result? A cycle of neglect that Justice in Aging's brief calls an "inequity in access to care and oral health outcomes," disproportionately hitting people of color, those with disabilities, and older adults with dementia.Who Lives in Nursing Facilities? A Snapshot of VulnerabilityPicture this: 82% of nursing home residents are 65 or older, with 73% white, 16% Black, and 6% Hispanic or Latino. But trends show growing diversity, especially in Medicaid-reliant facilities. About 28% hail from rural areas, where isolation amplifies challenges.
Health-wise, these aren't robust seniors; they're battling a storm of comorbidities. Nearly half have Alzheimer's or dementia; 46% heart disease; over a third have diabetes; and 74% hypertension. Oral health isn't a luxury here; it's intertwined with survival. Untreated decay can spike infection risks, worsening heart issues, or diabetes. Conversely, chronic conditions make brushing or flossing a Herculean task. As the brief notes, citing NIH research, this bidirectional link demands urgent intervention.
Funding adds insult to injury. Medicare covers only the first 100 days of skilled nursing care post-hospitalization, narrowly defined as services from RNs, therapists, or similar professionals. After that, it pays for doctor visits via Part B but skips room and board. Medicaid foots 62% of long-term stays, with 24% self-paying or using long-term care insurance. Yet Medicaid's adult dental coverage? Optional and patchy. Eight states offer coverage for emergencies only, 14 offer limited benefits, and even "extensive" coverage varies.The Stark Disparities: A Multi-Level CrisisNursing home residents don't just lack access, they suffer profoundly unequal outcomes. Barriers stack up at every level:

• Policy: No guaranteed dental coverage in Medicare or consistent Medicaid benefits.
• Organizational: Facilities short on space, staff training, or geriatric dentists.
• Individual: Frailty, dementia, or behavioral issues make care delivery a battle.

Data paints a grim picture. A California study found 30% of nursing home elders had untreated decay (compared to 18% of community-dwellers) and 27% edentulous (toothless, compared to 11%). Rural residents are 13% more likely to have decay. 
Racial gaps widen the challenge; black residents are 16% more likely to be edentulous than white; American Indian/Alaska Native folks are 34% more so, plus 20% higher cavity rates.
Chronic illnesses compound the challenge.  Residents with three or more conditions face skyrocketing odds of denture issues, pain, or chewing woes. Dementia hits hardest, with Black women (facing the top Alzheimer's rates) doubly vulnerable. Facilities in Black/Hispanic neighborhoods often deliver subpar care, per AARP data. Rural spots? 70% higher multi-dental problems.
These aren't isolated stats; they're symptoms of systemic failure, fueling ER visits, hospitalizations, and eroded well-being.Medicare Dental Expansion: The Game-ChangerEnter the fix: Fold dental into Medicare Part B as a standardized benefit for all 67.6 million enrollees—Original or Advantage. No more "inextricably linked" hoops or disease-specific qualifiers. Preventive cleanings, fillings, and more would be covered based on medical necessity, untethered from income, Medicaid status, or state whims.
Why transformative for nursing homes?

• Equity Boost: Uniform access, especially for Medicaid-heavy facilities where states slashed benefits amid 2025's Budget Reconciliation Act cuts.
• Provider Pull: Higher Medicare reimbursements (vs. Medicaid's stingy rates) lure dentists to facilities, easing logistics.
• Staff Relief: Simplified billing means less admin drudgery.
• Health Wins: Fewer complications, per studies on Medicaid dental cuts—saving lives and dollars.

Bills like H.R. 2045 (Medicare Dental, Vision, and Hearing Benefit Act of 2025) and S. 939 (Medicare Dental, Hearing, and Vision Expansion Act of 2025) are gaining traction. The passage of this legislation would be monumental.Beyond Coverage: Tackling the Full Spectrum of BarriersCoverage alone won't suffice, so Justice in Aging urges a three-pronged assault:

1. Ramp Up Oversight: Enforce federal regs requiring quarterly oral assessments and hygiene aid. Beef up CMS surveyor guidance; mandate staff training and oral pros for Minimum Data Sets.
2. Deliver Care On-Site: Leverage tele-dentistry for remote consults (proven equity-bridger for special needs). Expand teams with hygienists in alternative practice (like California's RDHAPs, slashing extractions via prevention) or community health workers.
3. Rural Integration: Combat shortages via medical-dental integration (MDI)—co-located care or primary docs doing basic screenings during wellness visits. Pilots show access surges and outcomes improve.

These aren't pie-in-the-sky; they're evidence-based levers to pull residents from crisis mode to proactive care.

Challenges for Homebound and Living at Home Seniors

Although the issue brief focuses on nursing homes, the harsh reality is that seniors aging in place at home face similar barriers to nursing home residents, though logistics differ. Mobility issues, lack of transportation, or rural isolation (noted in the brief as affecting 28% of nursing home residents, but also relevant at home) can make accessing dental care tough, even if covered by an MA plan.  Unlike nursing facilities, where federal regulations mandate oral health assessments and care coordination (42 CFR 483.20, 483.55), homebound seniors rely on their own or caregiver support to navigate care, amplifying disparities.

For dual-eligible seniors (Medicare and Medicaid), Medicaid may cover dental services, but this varies by state. As of 2022, eight states offer only emergency dental coverage, 14 provide limited benefits, and half offer more extensive coverage with variability. For homebound seniors, low Medicaid reimbursement rates and provider shortages (especially in rural areas) limit access.

The Justice in Aging brief advocates adding a dental benefit to Medicare Part B, which would cover preventive and medically necessary dental care for all enrollees, including those at home. Bills like H.R. 2045 and S. 939 (2025) propose this, potentially transforming access. If passed, this could mean homebound seniors get standardized coverage without relying on spotty MA plans or state Medicaid.

Moreover, even with coverage, homebound seniors face logistical hurdles. The brief highlights solutions like tele-dentistry or expanded dental teams (e.g., hygienists with broader scopes, like California’s RDHAPs), which could bring care to homes. Medical-dental integration (MDI) models, where primary care providers offer basic dental screenings during home visits, are also promising but not yet widespread.

What This Means for Seniors at HomeRight now, unless a senior’s dental needs tie directly to a covered medical procedure (e.g., pre-transplant exam), they’re likely paying out-of-pocket or relying on variable MA/Medicaid benefits. For homebound seniors, this is compounded by:

• Access Gaps: Few dentists make house calls, and rural areas (Dental Health Professional Shortage Areas) lack providers.
• Health Risks: Poor oral health worsens chronic conditions like diabetes or heart disease, common among seniors (46% heart disease, 33% diabetes per the brief), risking hospitalizations.
• Disparities: Black, Hispanic, and rural seniors face worse outcomes, with higher rates of tooth loss or untreated decay.

Simply, seniors seeking to age in place face the same or similar challenges and risks.

Recommendations for Seniors and Caregivers

• Check MA Plans: Review your Medicare Advantage plan’s dental benefits. Some cover routine care, but confirm provider networks and in-home care options.
• Explore Medicaid: If dual-eligible, check your state’s Medicaid dental coverage at CareQuest’s Dental Coverage Checker.
• Advocate for Change: Support bills like H.R. 2045/S. 939 by contacting representatives. Visit justiceinaging.org for advocacy tools.
• Leverage Community Resources: Look for local programs or mobile dental clinics, especially in rural areas. Ask primary care providers about MDI programs offering basic oral screenings.
• Plan Financially: For uncovered care, elder law attorneys can help integrate dental costs into long-term care plans or explore dental discount plans.

Looking AheadThe push to add dental to Medicare Part B could be a game-changer, ensuring seniors at home access preventive care without navigating a patchwork of plans. Until then, proactive planning and advocacy are key. Have you or a loved one faced dental care barriers at home? Share your story below to keep this conversation alive.
Sources: This article draws heavily and directly from Justice in Aging's October 2025 issue brief, with citations to original endnotes for deeper dives.