Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services and under which qualified low-income persons receive health care benefits. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Existing law provides that certain optional benefits, including, among others, certain adult dental services, are excluded from coverage under the Medi-Cal program. Existing law, beginning May 1, 2014, or the effective date of any necessary federal approvals, whichever is later, provides that only specified adult dental services are a covered Medi-Cal benefit for persons 21 years of age or older.

This bill would require the department to undertake specified activities for the purpose of improving the Medi-Cal Dental Program, such as expediting provider enrollment and monitoring dental service access and utilization. The bill would require a Medi-Cal managed care health plan to provide dental health screenings for eligible beneficiaries and refer them to appropriate Medi-Cal dental providers. This bill would provide that those provisions shall only be implemented to the extent that the department obtains any necessary federal approvals and federal matching funds.

Existing law requires the department to establish a list of performance measures to ensure the dental fee-for-service program meets quality and access criteria required by the department. Existing law requires the department to annually post on October 1 the list of performance measures and data of the dental fee-for-service program for the previous calendar year on its Internet Web site. Existing law also requires the department to establish a list of performance measures to ensure dental health plans meet quality criteria required by the department. Existing law requires the department to post, on a quarterly basis, the list of performance measures and each plans performance on the departments Internet Web site.

This bill would add performance measures to the lists for both the dental fee-for-service program and dental health plans described above, as specified. The bill would, as of October 31, 2016, eliminate the requirement that the department annually post the performance measures and program data relating to the dental fee-for-service program for the previous calendar year on October 1 and instead would require the department, commencing January 31, 2017, to post that information for the previous fiscal year on its Internet Web site on or before January 31 of each year. The bill, commencing April 30, 2017, and on specified dates thereafter, would require the department to post dental fee-for-service program performance data, the dental health plan performance measures, and each dental health plans performance on a quarterly basis for the preceding fiscal quarter on its Internet Web site. The bill would require the department to ensure, to the greatest degree possible, that the categories of data and performance measures selected for the dental fee-for-service program and for dental health plans are consistent with one another. The bill would require the department, no sooner than July 1, 2019, to annually publish specified utilization data for both the dental fee-for-service and dental managed care programs from the preceding calendar year and to make this information available on its Internet Web site.

Existing law establishes the Medi-Cal 2020 Demonstration Project Act, under which the department is required to implement specified components of a Medicaid 1115(a) demonstration project, referred to as Californias Medi-Cal 2020 demonstration project, consistent with the Special Terms and Conditions approved by the federal Centers for Medicare and Medicaid Services (CMS). Existing law requires the department to implement the Dental Transformation Initiative (DTI), a component of the Medi-Cal 2020 demonstration project, under which DTI incentive payments, as defined, within specified domain categories would be made available to qualified providers who meet achievements within one or more of the project domains, and would require the department to evaluate the DTI as required under the Special Terms and Conditions.

This bill would require, consistent with the Special Terms and Conditions and the evaluation requirement described above, the departments reports of data and quality measures submitted to CMS and made publicly available for each of the domain areas under the DTI to include specified information.

Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services and under which qualified low-income persons receive health care benefits. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Existing law provides that certain optional benefits, including, among others, certain adult dental services, are excluded from coverage under the Medi-Cal program. Existing law, beginning May 1, 2014, or the effective date of any necessary federal approvals, whichever is later, provides that only specified adult dental services are a covered Medi-Cal benefit for persons 21 years of age or older.

This bill would require the department to undertake specified activities for the purpose of improving the Medi-Cal Dental Program, such as expediting provider enrollment and monitoring dental service access and utilization. The bill would require a Medi-Cal managed care health plan to provide dental health screenings for eligible beneficiaries and refer them to appropriate Medi-Cal dental providers. This bill would provide that those provisions shall only be implemented to the extent that the department obtains any necessary federal approvals and federal matching funds.

Existing law requires the department to establish a list of performance measures to ensure the dental fee-for-service program meets quality and access criteria required by the department. Existing law requires the department to annually post on October 1 the list of performance measures and data of the dental fee-for-service program for the previous calendar year on its Internet Web site. Existing law also requires the department to establish a list of performance measures to ensure dental health plans meet quality criteria required by the department. Existing law requires the department to post, on a quarterly basis, the list of performance measures and each plans performance on the departments Internet Web site.

This bill would add performance measures to the lists for both the dental fee-for-service program and dental health plans described above, as specified. The bill would, as of October 31, 2016, eliminate the requirement that the department annually post the performance measures and program data relating to the dental fee-for-service program for the previous calendar year on October 1 and instead would require the department, commencing January 31, 2017, to post that information for the previous fiscal year on its Internet Web site on or before January 31 of each year. The bill, commencing April 30, 2017, and on specified dates thereafter, would require the department to post dental fee-for-service program performance data, the dental health plan performance measures, and each dental health plans performance on a quarterly basis for the preceding fiscal quarter on its Internet Web site. The bill would require the department to ensure, to the greatest degree possible, that the categories of data and performance measures selected for the dental fee-for-service program and for dental health plans are consistent with one another. The bill would require the department, no sooner than July 1, 2019, to annually publish specified utilization data for both the dental fee-for-service and dental managed care programs from the preceding calendar year and to make this information available on its Internet Web site.

Existing law establishes the Medi-Cal 2020 Demonstration Project Act, under which the department is required to implement specified components of a Medicaid 1115(a) demonstration project, referred to as Californias Medi-Cal 2020 demonstration project, consistent with the Special Terms and Conditions approved by the federal Centers for Medicare and Medicaid Services (CMS). Existing law requires the department to implement the Dental Transformation Initiative (DTI), a component of the Medi-Cal 2020 demonstration project, under which DTI incentive payments, as defined, within specified domain categories would be made available to qualified providers who meet achievements within one or more of the project domains, and would require the department to evaluate the DTI as required under the Special Terms and Conditions.

This bill would require, consistent with the Special Terms and Conditions and the evaluation requirement described above, the departments reports of data and quality measures submitted to CMS and made publicly available for each of the domain areas under the DTI to include specified information.

Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services and under which qualified low-income persons receive health care benefits. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Existing law provides that certain optional benefits, including, among others, certain adult dental services, are excluded from coverage under the Medi-Cal program. Existing law, beginning May 1, 2014, or the effective date of any necessary federal approvals, whichever is later, provides that only specified adult dental services are a covered Medi-Cal benefit for persons 21 years of age or older.

This bill would require the department to undertake specified activities for the purpose of improving the Medi-Cal Dental Program, such as expediting provider enrollment and monitoring dental service access and utilization. The bill would require a Medi-Cal managed care health plan to provide dental health screenings for eligible beneficiaries and refer them to appropriate Medi-Cal dental providers. This bill would provide that those provisions shall only be implemented to the extent that the department obtains any necessary federal approvals and federal matching funds.

Existing law requires the department to establish a list of performance measures to ensure the dental fee-for-service program meets quality and access criteria required by the department. Existing law requires the department to annually post on October 1 the list of performance measures and data of the dental fee-for-service program for the previous calendar year on its Internet Web site. Existing law also requires the department to establish a list of performance measures to ensure dental health plans meet quality criteria required by the department. Existing law requires the department to post, on a quarterly basis, the list of performance measures and each plans performance on the departments Internet Web site.

This bill would add performance measures to the lists for both the dental fee-for-service program and dental plans described above, as specified. The bill would, as of October 31, 2016, eliminate the requirement that the department annually post the performance measures and program data relating to the dental fee-for-service program for the previous calendar year on October 1 and instead would require the department, commencing January 31, 2017, to post that information for the previous fiscal year on its Internet Web site on or before January 31 of each year. The bill, commencing April 30, 2017, and on specified dates thereafter, would require the department to post dental fee-for-service program performance data, the dental health plan performance measures, and each dental health plans performance on a quarterly basis for the preceding fiscal quarter on its Internet Web site. The bill would require the department to ensure, to the greatest degree possible, that the categories of data and performance measures selected for the dental fee-for-service program and for dental health plans are consistent with one another. The bill would require the department, no sooner than July 1, 2019, to annually publish specified utilization data for both the dental fee-for-service and dental managed care programs from the preceding calendar year and to make this information available on its Internet Web site.

Existing law establishes the Medi-Cal 2020 Demonstration Project Act, under which the department is required to implement specified components of a Medicaid 1115(a) demonstration project, referred to as Californias Medi-Cal 2020 demonstration project, consistent with the Special Terms and Conditions approved by the federal Centers for Medicare and Medicaid Services (CMS). AB 1568 of the 201516 Regular Session, if enacted, would require Existing law requires the department to implement the Dental Transformation Initiative (DTI), a component of the Medi-Cal 2020 demonstration project, under which DTI incentive payments, as defined, within specified domain categories would be made available to qualified providers who meet achievements within one or more of the project domains, and would require the department to evaluate the DTI as required under the Special Terms and Conditions.

This bill would require, consistent with the Special Terms and Conditions and the evaluation requirement described above, the departments reports of data and quality measures submitted to CMS and made publicly available for each of the domain areas under the DTI to include specified information.

Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services and under which qualified low-income persons receive health care benefits. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Existing law provides that certain optional benefits, including, among others, certain adult dental services, are excluded from coverage under the Medi-Cal program. Existing law, beginning May 1, 2014, or the effective date of any necessary federal approvals, whichever is later, provides that only specified adult dental services are a covered Medi-Cal benefit for persons 21 years of age or older.

This bill would require the department to undertake specified activities for the purpose of improving the Medi-Cal Dental Program, such as expediting provider enrollment and monitoring dental service access and utilization. The bill would require a Medi-Cal managed care health plan to provide dental health screenings for eligible beneficiaries and refer them to appropriate Medi-Cal dental providers. This bill would provide that those provisions shall only be implemented to the extent that the department obtains any necessary federal approvals and federal matching funds.

Existing law requires the department to establish a list of performance measures to ensure the dental fee-for-service program meets quality and access criteria required by the department. Existing law requires the department to annually post on October 1 the list of performance measures and data of the dental fee-for-service program for the previous calendar year on its Internet Web site. Existing law also requires the department to establish a list of performance measures to ensure dental health plans meet quality criteria required by the department. Existing law requires the department to post, on a quarterly basis, the list of performance measures and each plans performance on the departments Internet Web site.

This bill would add performance measures to the performance measures lists for both the dental fee-for-service program and dental plans described above the total number of patients seen on a per-provider basis and the total number of dental services rendered by each provider during each calendar year. above, as specified. The bill would, as of October 31, 2016, eliminate the requirement that the department annually post the performance measures and program data relating to the dental fee-for-service program for the previous calendar year on October 1 and instead would require the department, commencing January 31, 2017, to post that information for the previous fiscal year on its Internet Web site on or before January 31 of each year. The bill, commencing April 30, 2017, and on specified dates thereafter, would require the department to post dental fee-for-service program performance data, the dental health plan performance measures, and each dental health plans performance on a quarterly basis for the preceding fiscal quarter on its Internet Web site. The bill would require the department to ensure, to the greatest degree possible, that the categories of data and performance measures selected for the dental fee-for-service program and for dental health plans are consistent with one another.

SB 815 of the 201516 Regular Session, if enacted, would establish the Medi-Cal 2020 Demonstration Project Act, under which the department is required to implement specified components of a Medicaid 1115(a) demonstration project, referred to as Californias Medi-Cal 2020 demonstration project, consistent with the Special Terms and Conditions approved by the federal Centers for Medicare and Medicaid Services. Services (CMS). AB 1568 of the 201516 Regular Session, if enacted, would require the department to implement the Dental Transformation Initiative (DTI), a component of the Medi-Cal 2020 demonstration project, under which DTI incentive payments, as defined, within specified domain categories would be made available to qualified providers who meet achievements within one or more of the project domains, and would require the department to evaluate the DTI as required under the Special Terms and Conditions.

This bill would require, consistent with the Special Terms and Conditions and the evaluation requirement described above, the departments reports of data and quality measures submitted to CMS and made publicly available for each of the domain areas under the DTI to include specified information.

Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services and under which qualified low-income persons receive health care benefits. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Existing law provides that certain optional benefits, including, among others, certain adult dental services, are excluded from coverage under the Medi-Cal program. Existing law, beginning May 1, 2014, or the effective date of any necessary federal approvals, whichever is later, provides that only specified adult dental services are a covered Medi-Cal benefit for persons 21 years of age or older.

This bill would require the department to undertake specified activities for the purpose of improving the Medi-Cal Dental Program, such as expediting provider enrollment and monitoring dental service access and utilization. The bill would require a Medi-Cal managed care health plan to provide dental health screenings for eligible beneficiaries and refer them to appropriate Medi-Cal dental providers. This bill would provide that those provisions shall only be implemented to the extent that the department obtains any necessary federal approvals, approvals and federal matching funds, and an appropriation in the annual Budget Act for the specific purpose of implementing those provisions. funds.

Existing law requires the department to establish a list of performance measures to ensure the dental fee-for-service program meets quality and access criteria required by the department. Existing law requires the department to annually post on October 1 the list of performance measures and data of the dental fee-for-service program for the previous calendar year on its Internet Web site. Existing law also requires the department to establish a list of performance measures to ensure dental health plans meet quality criteria required by the department. Existing law requires the department to post, on a quarterly basis, the list of performance measures and each plans performance on the departments Internet Web site.

This bill would add to the performance measures for both the dental fee-for-service program and dental plans described above the total number of patients seen on a per-provider basis and the total number of dental services rendered by each provider during each calendar year. The bill would, as of October 31, 2016, eliminate the requirement that the department annually post the performance measures and program data relating to the dental fee-for-service program for the previous calendar year on October 1 and instead would require the department, commencing January 31, 2017, to post that information for the previous fiscal year on its Internet Web site on or before January 31 of each year. The bill, commencing April 30, 2017, and on specified dates thereafter, would require the department to post dental fee-for-service program performance data, the dental health plan performance measures, and each dental health plans performance on a quarterly basis for the preceding fiscal quarter on its Internet Web site. The bill would require the department to ensure, to the greatest degree possible, that the categories of data and performance measures selected for the dental fee-for-service program and for dental health plans are consistent with one another.

Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services and under which qualified low-income persons receive health care benefits. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Existing law provides that certain optional benefits, including, among others, certain adult dental services, are excluded from coverage under the Medi-Cal program. Existing law, beginning May 1, 2014, or the effective date of any necessary federal approvals, whichever is later, provides that only specified adult dental services are a covered Medi-Cal benefit for persons 21 years of age or older.

This bill would require the department to undertake specified activities for the purpose of improving the Medi-Cal Dental Program, such as expediting provider enrollment and monitoring dental service access and utilization. The bill would require a Medi-Cal managed care health plan to provide dental health screenings for eligible beneficiaries and refer them to appropriate Medi-Cal dental providers. This bill would provide that those provisions shall only be implemented to the extent that the department obtains necessary federal approvals, federal matching funds, and an appropriation in the annual Budget Act for the specific purpose of implementing those provisions.

Existing law requires the department to establish a list of performance measures to ensure the dental fee-for-service program meets quality and access criteria required by the department. Existing law requires the department to annually post on October 1 the list of performance measures and data of the dental fee-for-service program for the previous calendar year on its Internet Web site. Existing law also requires the department to establish a list of performance measures to ensure dental health plans meet quality criteria required by the department. Existing law requires the department to post, on a quarterly basis, the list of performance measures and each plans performance on the departments Internet Web site.

This bill, bill would add to the performance measures for both the dental fee-for-service program and dental plans described above the total number of patients seen on a per-provider basis and the total number of dental services rendered by each provider during each calendar year. The bill would, as of October 31, 2016, would eliminate the requirement that the department annually post the performance measures and program data relating to the dental fee-for-service program for the previous calendar year on October 1 and instead would require the department, commencing January 31, 2017, to post that information for the previous fiscal year on its Internet Web site on or before January 31 of each year. The bill, commencing April 30, 2017, and on specified dates thereafter, would require the department to post dental fee-for-service program performance data, the dental health plan performance measures, and each dental health plans performance on a quarterly basis for the preceding fiscal quarter on its Internet Web site. The bill would require the department to ensure, to the greatest degree possible, that the categories of data and performance measures selected for the dental fee-for-service program and for dental health plans are consistent with one another.

Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services and under which qualified low-income persons receive health care benefits. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Existing law provides that certain optional benefits, including, among others, certain adult dental services, are excluded from coverage under the Medi-Cal program. Existing law, beginning May 1, 2014, or the effective date of any necessary federal approvals, whichever is later, provides that only specified adult dental services are a covered Medi-Cal benefit for persons 21 years of age or older.

This bill would require the department to undertake specified activities for the purpose of improving the Medi-Cal Dental Program, such as expediting provider enrollment and monitoring dental service access and utilization. The bill would require a Medi-Cal managed care health plan to provide dental health screenings for eligible beneficiaries and refer them to appropriate Medi-Cal dental providers. This bill would provide that those provisions shall only be implemented to the extent that the department obtains necessary federal approvals, federal matching funds, and an appropriation in the annual Budget Act for the specific purpose of implementing those provisions.

Existing law requires the department to establish a list of performance measures to ensure the dental fee-for-service program meets quality and access criteria required by the department. Existing law requires the department to annually post on October 1 the list of performance measures and data of the dental fee-for-service program for the previous calendar year on its Internet Web site. Existing law also requires the department to establish a list of performance measures to ensure dental health plans meet quality criteria required by the department. Existing law requires the department to post, on a quarterly basis, the list of performance measures and each plans performance on the departments Internet Web site.

This bill, as of October 31, 2016, would eliminate the requirement that the department annually post the performance measures and program data relating to the dental fee-for-service program for the previous calendar year on October 1 and instead would require the department, commencing January 31, 2017, to post that information for the previous fiscal year on its Internet Web site on or before January 31 of each year. The bill, commencing April 30, 2017, and on specified dates thereafter, would require the department to post dental fee-for-service program performance data, the dental health plan performance measures, and each dental health plans performance on a quarterly basis for the preceding fiscal quarter on its Internet Web site. The bill would require the department to ensure, to the greatest degree possible, that the categories of data and performance measures selected for the dental fee-for-service program and for dental health plans are consistent with one another.

CONCURRENCE IN SENATE AMENDMENTS

CSA1 Bill Id:AB 2207

Author:(Wood)

As Amended Ver:August 15, 2016

Majority vote

Original Committee Reference: HEALTH

SUMMARY: Makes changes to the Medi-Cal dental program (Denti-Cal) provider enrollment and disenrollment process, increases access and utilization oversight responsibility of the Department of Health Care Services (DHCS) over Denti-Cal contracts, and aligns Denti-Cal fee-for-service (FFS) and Dental managed care (DMC) annual and quarterly data reporting requirements. Specifically, this bill:

1. Requires quarterly (instead of annual) posting of the data of the Denti-Cal FFS and DMC program performance measures to be posted on DHCS' Internet Web site, beginning April 1, 2017. Aligns the timing of the Denti-Cal FFS and managed care reports.
2. Requires DHCS to ensure, to the greatest degree possible, that the categories of data and performance measures selected for Denti-Cal FFS are consistent with the categories of data and performance measures selected for DMC plans.
3. Requires DHCS to expedite the enrollment of Denti-Cal providers by streamlining the Medi-Cal provider enrollment process by creating a dental-specific enrollment form, pursuing an alternative automatic enrollment process for a provider already commercially credentialed, and other activities, as specified.
4. Requires DHCS to maintain the provider network by disenrolling a billing and rendering provider who has not, over a continuous 12-month period, submitted a claim for reimbursement for services rendered.
5. Requires DHCS to disenroll a provider who has not participated in the dental program, as determined by DHCS, for more than a continuous one-year period. Permits DHCS to exercise additional measures as appropriate in order to improve the quality of the dental provider network, including, but not limited to, temporary suspensions.
6. Requires DHCS to monitor access and utilization of Denti-Cal services in the FFS and DMC delivery systems to assess opportunities to improve access and utilization and assess opportunities to develop and implement innovative payment reform proposals within Denti-Cal.
7. Requires DHCS to explore additional opportunities in consultation with stakeholders, to improve the Denti-Cal, as specified.
8. Allows DHCS to implement, interpret, or make specific policies and procedures by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions, requires DHCS to thereafter adopt regulations, and requires DHCS to update the legislature until regulations are adopted.
9. Makes implementation of most of its provisions contingent upon federal approval, availability of federal matching funds, and an appropriation in the annual Budget Act each fiscal year for the specific purpose of implementation.
10. Contains other provisions to improve Denti-Cal accountability, transparency, and quality.

The Senate amendments

1. Require DHCS, no sooner than July 1, 2019, to annually publish the following utilization data from the preceding calendar year and post the information on its internet Web site:
   1. Number of patients seen on a per-provider basis;
   2. Number of annual preventative dental services dental treatment services, examinations, and oral health evaluations rendered by each provider during each calendar year; and,
   3. The number of beneficiaries who received general anesthesia services.
2. Require DHCS to maintain the provider network on a monthly basis and clarify procedures regarding the deactivation and disenrollment of Denti-Cal providers.
3. Specify that a provider who has not submitted a claim for reimbursement of services rendered in one continuous 12 month period be deactivated and, at the time of deactivation, require DHCS to send a notification to the provider informing them of their ability to request reactivation.
4. Specify that a Denti-Cal provider be disenrolled 6 months after DHCS has notified them of their deactivation status.
5. Make provisions in 2) through 4) above, operational once DHCS has implemented necessary system changes to the California Dental Medicaid Management Information or July 1, 2017, whichever is later.
6. Specify requirements for DHCS to work with Denti-Cal managed care plans that contract with DHCS to provide beneficiaries with access to dental plan liaisons to assist with referrals to health plan covered services.
7. Codify the Dental Transformation Initiative (DTI) data reporting and evaluation quality measure requirements required to be reported to the federal government and made publicly available for each of the four DTI domains contained in the Special Terms and Conditions of Medi-Cal 2020, the state's Section 1115 Medicaid waiver.

FISCAL EFFECT: According to the Senate Appropriations Committee:

1. One-time costs of $370,000 and ongoing costs of $340,000 per year for additional collection, analysis, and reporting of new performance measures by the Department of Health Care Services (General Fund and federal funds).
2. Unknown costs to make administrative changes to the system for enrolling Denti-Cal providers (General Fund and federal funds). This bill requires the Department to make several changes to the processes and systems for enrolling dental providers into the program, such as requiring the use of a dental-specific enrollment form, pursuing an automatic enrollment process for commercially-credentialed providers, and improving the system for maintaining the provider network. The Department has already begun some of these processes, such as simplifying the paper enrollment application. Other activities, such as automatically enrolling commercially-credentialed providers have not begun and will impose unknown administrative costs to implement. On the other hand, improvements to the system for provider enrollment may reduce future administrative workload to process enrollment applications, which are currently very labor intensive to the Department and its fiscal intermediary.
3. Unknown costs to provide additional Denti-Cal services, to the extent that the changes in the bill improve participation rates by dental providers, increasing the utilization of Denti-Cal services (General Fund and federal funds). Currently, the state spends about $1.2 billion per year on Denti-Cal for adults and children. Estimates of the utilization rates, but are all generally low. There are strong indications that low reimbursement rates and cumbersome administrative requirements on providers result in low participation rates by providers. To the extent that the administrative changes in the bill improve provider participation, there could be increased utilization. For example, for every 5% increase in annual utilization by children, the cost would be about $35 million per year.
4. Unknown potential cost-savings due to increased use of preventative dental services (General Fund and federal funds). Regular dental care, particularly for children, is likely to prevent dental conditions, such as cavities, from becoming more serious health problems that require more costly interventions later. To the extent that the bill results in increased utilization of preventative dental services in Denti-Cal, there are likely to be reduced costs for more serious dental services. Whether those avoided costs are greater than the cost of providing greater access to preventative services is unknown.

COMMENTS: According to the author, dental care consistently ranks with the public as the most important type of health care after medical. The impact that good dental hygiene and health has on people's self-esteem and quality of life cannot be understated. Dentistry is about prevention in order to avoid costly intervention at a later date; however, our system for participation and enrollment does not currently reflect that. Participation and entry to the program as a participating provider should be easy with restrictions and limiting parameters put in place only when a dentist's pattern of behavior warrants such. The limited number of private practitioners able to participate in the program is concerning due to the geographic limitations this can create. There are counties in California with just a couple of dentists participating in the program and too often these are older dentists who will be retiring soon, with no dentists able to take their place.

The author states that the Denti-Cal system is so broken that many dentists provide pro-bono care as opposed to taking Denti-Cal because they both give back to their community and society and manage it in a way that it is not financially devastating to their practices. The real loss in this system rests with beneficiaries.

Denti-Cal. States are federally required to provide dental benefits to children covered by Medicaid (Medi-Cal in California) and the Children's Health Insurance Program. Denti-Cal is the Medicaid program that provides comprehensive dental care to pediatric and pregnant Medi-Cal beneficiaries and limited emergency services to adult beneficiaries. While Medicaid covers dental services for all child enrollees as part of a comprehensive set of benefits, referred to as the Early and Periodic Screening, Diagnostic and Treatment benefit, states may choose whether to provide dental benefits for adults. Minimum federal requirements for pediatric dental Medicaid programs include relief of pain and infections, restoration of teeth and maintenance of dental health. For children in Medi-Cal, dental care is provided on a FFS basis in all counties, with Sacramento and Los Angeles Counties also offering services through DMC plans.

For more than 40 years Medicaid-enrolled Californians of any age were eligible for basic diagnostic, preventive, restorative and emergency dental procedures provided by participating dentists through Denti-Cal. In 2007, Denti-Cal provided comprehensive oral health care to more than eight million people. However, from July 2009 to May 2014, California eliminated funding for most adult non-emergency Denti-Cal benefits, effectively eliminating California's oral health safety-net. A partial restoration of benefits, primarily diagnostic and preventative services, was enacted in the 2013 Budget Act and became effective May 1, 2014.

State Auditor's Report. On December 11, 2014, the California State Auditor issued a report titled "California Department of Health Care Services: Weaknesses in Its Denti-Cal Limit Children's Access to Dental Care." The report stated that insufficient number of dental providers willing to participate in Medi-Cal, low reimbursement rates and a failure to adequately monitor the program, led to limited access to care and low utilization rates for Medi-Cal beneficiaries across the state. The Audit found that 16 counties either have no active providers or do not have providers willing to accept new Medi-Cal patients, and 16 other counties have an insufficient number of providers. Recent changes in federal and state laws that have expanded Medi-Cal coverage could increase the number of children and adults who can receive additional covered dental services from 2.7 million to as many as 6.4 million, bringing into question the state's ability to provide timely and adequate care to beneficiaries.

Little Hoover Commission (LHC) Report. On April 1, 2016, the LHC published a report titled "Fixing Denti-Cal." The LHC initiated an examination of the state's Denti-Cal program after receiving formal requests for a review from Legislators in April of 2015 and following the findings of the 2014 State Auditor's Report. Lawmakers requested that the LHC "undertake a review of the Denti-Cal program and identify the necessary steps to assure this vital program meets its purpose to provide access to dental care for many of the most vulnerable Californians including children." The LHC Report highlighted the lack of providers in the Denti-Cal program, inadequate and low provider reimbursement rates, enrollment, billing, and administrative challenges.

Analysis Prepared by: Paula Villescaz / HEALTH / (916) 319-2097 FN: 0004210

SENATE COMMITTEE ON APPROPRIATIONS

Senator Ricardo Lara, Chair

2015 - 2016 Regular Session

AB 2207 (Wood) - Medi-Cal: dental program

*********** ANALYSIS ADDENDUM – SUSPENSE FILE ***********

The following information is revised to reflect amendments

adopted by the committee on August 11, 2016

Bill Summary:

AB 2207 would enact an number of changes to the operation of the Denti-Cal program, relating to provider enrollment, program monitoring, and reporting.

Fiscal Impact:

• One-time costs of $370,000 and ongoing costs of $340,000 per year for additional collection, analysis, and reporting of new performance measures by the Department of Health Care Services (General Fund and federal funds).
• Unknown costs to make administrative changes to the system for enrolling Denti-Cal providers (General Fund and federal funds). The bill requires the Department to make several changes to the processes and systems for enrolling dental providers into the program, such as requiring the use of a dental-specific enrollment form, pursuing an automatic enrollment process for commercially-credentialed providers, and improving the system for maintaining the provider network. The Department has already began some of these processes, such as simplifying the paper enrollment application. Other activities, such as automatically enrolling commercially-credentialed providers have not begun and will impose unknown administrative costs to implement. On the other hand, improvements to the system for provider enrollment may reduce future administrative workload to process enrollment applications, which are currently very labor intensive to the Department and its fiscal intermediary.
• Unknown costs to provide additional Denti-Cal services, to the extent that the changes in the bill improve participation rates by dental providers, increasing the utilization of Denti-Cal services (General Fund and federal funds). Currently, the state spends about $1.2 billion per year on Denti-Cal for adults and children. Estimates of the utilization rates vary, but are all generally low. There are strong indications that low reimbursement rates and cumbersome administrative requirements on providers result in low participation rates by providers. To the extent that the administrative changes in the bill improve provider participation, there could be increased utilization. For example, for every 5% increase in annual utilization by children, the cost would be about $35 million per year.
• Unknown potential cost-savings due to increased use of preventative dental services (General Fund and federal funds). Regular dental care, particularly for children, is likely to prevent dental conditions, such as cavities, from becoming more serious health problems that require more costly interventions later. To the extent that the bill results in increased utilization of preventative dental services in Denti-Cal, there are likely to be reduced costs for more serious dental services. Whether those avoided costs are greater than the cost of providing greater access to preventative services is unknown.

Author Amendments:

Clarify the requirements for deactivating a Denti-Cal provider, delay implementation for the collection of certain data, and make technical changes.

-- END --

 THIRD READING  

Bill No: AB 2207

Author: Wood (D)

Amended: 8/15/16 in Senate

Vote: 21

SENATE HEALTH COMMITTEE: 9-0, 6/22/16

AYES: Hernandez, Nguyen, Hall, Mitchell, Monning, Nielsen, Pan, Roth, Wolk

SENATE APPROPRIATIONS COMMITTEE: 7-0, 8/11/16

AYES: Lara, Bates, Beall, Hill, McGuire, Mendoza, Nielsen

ASSEMBLY FLOOR: 80-0, 5/31/16 - See last page for vote

SUBJECT: Medi-Cal: dental program

SOURCE: Author

DIGEST: This bill requires the Department of Health Care Services (DHCS) to expedite the Medi-Cal dental program (Denti-Cal) provider enrollment process, including an alternative automatic enrollment process for a provider already commercially enrolled, subject to federal approval. Requires automatic deactivation of a dental provider who has not submitted a claim over a continuous 12-month period, after notice to the provider. Requires DHCS to monitor access and utilization of Denti-Cal services to assess opportunities to improve access and utilization. Expands and aligns Denti-Cal fee-for-service and Denti-Cal managed care annual reporting requirements, and requires quarterly data reporting requirements. Codifies the data reporting and evaluation requirements for the Dental Transformation Initiative in the state’s “Medi-Cal 2020” Section 1115 waiver.

ANALYSIS:

Existing law:

1. Establishes the Medi-Cal program, which is administered by DHCS, under which qualified low-income individuals receive health care services, including certain dental services, as specified. Dental services are delivered through the fee-for-service (FFS) Denti-Cal program, except in Sacramento County, where enrollment in a dental managed care plan is required (with exceptions), and in Los Angeles County, where beneficiaries have the option to enroll in a dental managed care plan.
2. Requires DHCS to establish a list of performance measures to ensure the FFS Denti-Cal program meets quality and access criteria required by DHCS. Requires the performance measures to be designed to evaluate utilization, access, availability, and effectiveness of preventive care and treatment.
3. Requires DHCS to establish measures to monitor the dental FFS Denti-Cal program, and requires specific performance measures for children, and a more limited set of performance measures for adults.
4. Requires DHCS to establish a list of performance measures to ensure Denti-Cal dental health plans meet quality criteria required by DHCS. Requires the list to specify the benchmarks used by DHCS to determine whether and the extent to which a dental health plan meets each performance measure.

This bill:

1. Requires the FFS Denti-Cal performance measures for adults and children to include specified measures, including number of applications of fluoride varnishes, and number of beneficiaries requiring general anesthesia to perform procedures.
2. Requires, no sooner than July 1, 2019, DHCS to annually publish and post on its Internet Web site utilization data from the preceding calendar year for FFS and managed care on specified utilization measures.
3. Requires quarterly (instead of annual) posting of the data of the Denti-Cal dental FFS and managed care program performance measures to be posted on DHCS’ Internet Web site, beginning April 1, 2017. Aligns the timing of the Denti-Cal FFS and managed care reports.
4. Requires DHCS to ensure, to the greatest degree possible, that the categories of data and performance measures selected for Denti-Cal FFS are consistent with the categories of data and performance measures selected for Denti-Cal managed care plans.
5. Requires DHCS to expedite the enrollment of Medi-Cal dental providers by streamlining the Medi-Cal provider enrollment process. Requires DHCS to pursue and implement all of the following activities, to the extent permitted by federal law:

a) Create a dental-specific enrollment form.

b) Pursue an alternative automatic enrollment process for a provider already commercially credentialed by either a dental FFS contractor or an administrative services contractor for the purpose of providing services as a commercial provider.

c) Discontinue requiring providers to resubmit an enrollment application that has been deemed incomplete if the missing information is available elsewhere within the application packet; and,

d) To publish the criteria for those processes in applicable provider bulletins and manuals, to the extent that DHCS expedites the enrollment of Medi-Cal dental providers by streamlining the Medi-Cal provider enrollment process.

1. Requires DHCS to maintain the provider network on a monthly basis by deactivating a billing provider who has not, over a continuous 12-month period, submitted a claim for reimbursement for services rendered.
2. Requires DHCS, prior to deactivating a provider, to send a notice to the provider that the provider will be deactivated from the dental program six months after the date of the notice. Prohibits DHCS from deactivating a provider until six months after the date of that notice.
3. Requires DHCS, in order to improve the quality of the dental provider network, to also exercise additional measures as appropriate and permitted by law, including, but not limited to, temporary suspensions. Requires the parameters and criteria developed by DHCS for additional measures for disenrollments to be published in applicable provider bulletins and manuals.
4. Requires DHCS to monitor access and utilization of Medi-Cal dental services in the FFS and managed care delivery systems to assess opportunities to improve access and utilization, including an annual review of the treatment authorization process.
5. Requires DHCS to assess opportunities to develop and implement innovative payment reform proposals within the Medi-Cal dental programs.
6. Requires DHCS to explore additional opportunities to improve the Medi-Cal Dental Program, in consultation with stakeholders and as deemed appropriate by the DHCS and to the extent permitted by federal law, including, but not limited to, the following:
7. Aligning the provision of dental anesthesia services with that of medical anesthesia services, including the ability to bill for applicable facility fees and ancillary services;
8. Adjusting other utilization controls for specialty services, as appropriate, to promote access to care while still protecting program integrity; and,
9. Expanding the scope of beneficiary outreach activities required by an entity that is contracted with DHCS to more broadly address underutilization throughout the state.
10. Requires DHCS, prior to implementing an action pursuant to 10) above, to post the proposed action on its Internet Web site at least 30 days before implementation.
11. Requires DHCS to work with Denti-Cal managed care plans that contract with DHCS to provide beneficiaries with access to dental plan liaisons to assist in the coordination of care for enrolled members.
12. Requires a Medi-Cal managed care health plan to do all of the following:
13. Provide dental screenings for every eligible beneficiary as a part of the beneficiary’s initial health assessment;
14. Ensure that an eligible beneficiary is referred to an appropriate Medi-Cal dental provider; and,
15. Identify plan liaisons available to dental managed care contractors and dental FFS contractors to assist with referrals to health plan covered services that may be needed by the beneficiary to aid in the treatment of an identified oral health care condition.
16. Exempts any contract amendment, modification, or change order to any contract entered into by DHCS for the purpose of implementing the state Medi-Cal Dental Program from specified provisions of the Public Contract and Government Codes, in addition to any policies, procedures, or regulations authorized by those provisions. Prohibits this provision from exempting DHCS from establishing a competitive bid process for awarding new fiscal intermediary contracts, as well as for awarding new Denti-Cal managed care contracts.
17. Requires DHCS, prior to implementing any change under this bill, to consult with, and provide notification to, stakeholders, including representatives from counties, local dental societies, nonprofit entities, legal aid entities, and other interested parties.
18. Requires DHCS to implement, interpret, or make specific policies and procedures pertaining to the dental FFS program and dental managed care plans, as well as applicable federal waivers and state plan amendments, including the provisions set forth in this bill, by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions without taking regulatory action, until regulations are adopted.
19. Requires DHCS, no later than December 31, 2018, to adopt regulations in accordance with the Administrative Procedures Act. Requires DHCS to provide a status report to the Legislature on a semiannual basis until regulations have been adopted beginning six months after the effective date of this bill.
20. Implements this bill only to the extent that DHCS obtains any federal approvals necessary to implement this bill and obtains federal matching funds to the extent permitted by federal law.
21. Codifies the Dental Transformation Initiative (DTI) data reporting and evaluation quality measure requirements required to be reported to the federal government and made publicly available for each of the four DTI domains contained in the Special Terms and Conditions (STCs) of Medi-Cal 2020, the state’s Section 1115 Medicaid waiver.

Comments

1. Author’s statement. According to the author, dental care consistently ranks with the public as the most important type of health care after medical. The impact that good dental hygiene and health has on people’s self-esteem and quality of life cannot be understated. Dentistry is about prevention in order to avoid costly intervention at a later date; however, California’s system for participation and enrollment does not currently reflect that.

The Denti-Cal system is so broken that many dentists provide pro-bono care as opposed to taking Denti-Cal because they both give back to their community and society and manage it in a way that it is not financially devastating to their practices. The real loss in this system rests with beneficiaries. A 2014 California State Auditor report indicated that the insufficient number of dental providers willing to participate in Denti-Cal, low reimbursement rates, and a failure to adequately monitor the program, led to limited access to care and low utilization rates for Denti-Cal beneficiaries across the state. The Audit found that almost half of eligible beneficiaries did not receive dental care they were eligible for. Additionally, an April 2016 Little Hoover Commission (LHC) Report indicated that with dreadful reimbursement rates for dentists and slow, outdated paper-based administrative and billing processes that compare poorly with those of commercial insurers, Denti-Cal has thoroughly alienated its partners in the dental profession. Most California dentists want nothing to do with Denti-Cal and consequently, more than 13 million people eligible for coverage have limited or no access to dentists.

This is unacceptable, and we must take action to change the system. While the provisions in this bill seem modest, they are significant steps towards improving the Denti-Cal program. This bill will streamline the enrollment process for providers, ensure that provider networks are up-to-date so that beneficiaries can more easily access providers, improve coordination of care for beneficiaries, and increases DHCS oversight of the Denti-Cal program.

FISCAL EFFECT: Appropriation: No Fiscal Com.: Yes Local: No

According to the Senate Appropriations Committee:

1. One-time costs of $370,000 and ongoing costs of $340,000 per year for additional collection, analysis, and reporting of new performance measures by DHCS (General Fund/GF and federal funds).
2. Unknown costs to make administrative changes to the system for enrolling Denti-Cal providers (GF and federal funds). The bill requires DHCS to make several changes to the processes and systems for enrolling dental providers into the program, such as requiring the use of a dental-specific enrollment form, pursuing an automatic enrollment process for commercially-credentialed providers, and improving the system for maintaining the provider network. DHCS has already began some of these processes, such as simplifying the paper enrollment application. Other activities, such as automatically enrolling commercially-credentialed providers have not begun and will impose unknown administrative costs to implement. On the other hand, improvements to the system for provider enrollment may reduce future administrative workload to process enrollment applications, which are currently very labor intensive to DHCS and its fiscal intermediary.
3. Unknown costs to provide additional Denti-Cal services, to the extent that the changes in the bill improve participation rates by dental providers, increasing the utilization of Denti-Cal services (General Fund and federal funds). Currently, the state spends about $1.2 billion per year on Denti-Cal for adults and children. Estimates of the utilization rates vary, but are all generally low. There are strong indications that low reimbursement rates and cumbersome administrative requirements on providers result in low participation rates by providers. To the extent that the administrative changes in the bill improve provider participation, there could be increased utilization. For example, for every 5% increase in annual utilization by children, the cost would be about $35 million per year.
4. Unknown potential cost-savings due to increased use of preventative dental services (GF and federal funds). Regular dental care, particularly for children, is likely to prevent dental conditions, such as cavities, from becoming more serious health problems that require more costly interventions later. To the extent that the bill results in increased utilization of preventative dental services in Denti-Cal, there are likely to be reduced costs for more serious dental services. Whether those avoided costs are greater than the cost of providing greater access to preventative services is unknown.

SUPPORT: (Verified 8/12/16)

California Coverage and Health Initiatives

California Dental Association

California Pan-Ethnic Health Network

California Primary Care Association

Children Now

Children’s Defense Fund-California

Children’s Partnership

County Health Executives Association of California

First 5 Association of California

Little Hoover Commission

National Association of Social Workers, California Chapter

Nurse-Family Partnership

OPPOSITION: (Verified 8/12/16)

None received

ARGUMENTS IN SUPPORT: The Little Hoover Commission (LHC), in its 2016 report, Fixing Denti-Cal, found the program to be lacking in multiple areas. The LHC made several recommendations aimed at expanding access to Denti-Cal services, with an ultimate goal of 66% of Denti-Cal-eligible children making annual dental visits. Several of those recommendations would require DHCS to take administrative actions to improve Denti-Cal. This bill calls on DHCS to expedite provider enrollment by creating a dental-specific enrollment form and pursuing alternative automatic enrollment for dentists already established commercially. This bill also requires DHCS to monitor access and utilization and explore additional opportunities to improve Denti-Cal. The LHC indicates it supports this bill because it requires DHCS to improve and expand Denti-Cal provider enrollment, and shares the LHC’s overall goal of expanding access to care.

The County Health Executives Association of California states that this bill proposes modest changes to the program, including expediting dental provider enrollment into the Medi-Cal program, ensuring screenings are provided for every eligible Medi-Cal beneficiary as part of their initial health assessment, and ensuring beneficiaries are referred to appropriate Medi-Cal dental providers, which could improve the delivery of dental services to those most in need in California.

ASSEMBLY FLOOR: 80-0, 5/31/16

AYES: Achadjian, Alejo, Travis Allen, Arambula, Atkins, Baker, Bigelow, Bloom, Bonilla, Bonta, Brough, Brown, Burke, Calderon, Campos, Chang, Chau, Chávez, Chiu, Chu, Cooley, Cooper, Dababneh, Dahle, Daly, Dodd, Eggman, Frazier, Beth Gaines, Gallagher, Cristina Garcia, Eduardo Garcia, Gatto, Gipson, Gomez, Gonzalez, Gordon, Gray, Grove, Hadley, Harper, Roger Hernández, Holden, Irwin, Jones, Jones-Sawyer, Kim, Lackey, Levine, Linder, Lopez, Low, Maienschein, Mathis, Mayes, McCarty, Medina, Melendez, Mullin, Nazarian, Obernolte, O'Donnell, Olsen, Patterson, Quirk, Ridley-Thomas, Rodriguez, Salas, Santiago, Steinorth, Mark Stone, Thurmond, Ting, Wagner, Waldron, Weber, Wilk, Williams, Wood, Rendon

Prepared by: Scott Bain / HEALTH / (916) 651-4111

8/16/16 9:46:15

**** END ****

SENATE COMMITTEE ON

Senator Ricardo Lara, Chair

2015 - 2016 Regular Session

AB 2207 (Wood) - Medi-Cal: dental program

This bill meets the criteria for referral to the Suspense File.

Bill Summary:

AB 2207 would enact an number of changes to the operation of the Denti-Cal program, relating to provider enrollment, program monitoring, and reporting.

Fiscal Impact:

• One-time costs of $370,000 and ongoing costs of $340,000 per year for additional collection, analysis, and reporting of new performance measures by the Department of Health Care Services (General Fund and federal funds).
• Unknown costs to make administrative changes to the system for enrolling Denti-Cal providers (General Fund and federal funds). The bill requires the Department to make several changes to the processes and systems for enrolling dental providers into the program, such as requiring the use of a dental-specific enrollment form, pursuing an automatic enrollment process for commercially-credentialed providers, and improving the system for maintaining the provider network. The Department has already began some of these processes, such as simplifying the paper enrollment application. Other activities, such as automatically enrolling commercially-credentialed providers have not begun and will impose unknown administrative costs to implement. On the other hand, improvements to the system for provider enrollment may reduce future administrative workload to process enrollment applications, which are currently very labor intensive to the Department and its fiscal intermediary.
• Unknown costs to provide additional Denti-Cal services, to the extent that the changes in the bill improve participation rates by dental providers, increasing the utilization of Denti-Cal services (General Fund and federal funds). Currently, the state spends about $1.2 billion per year on Denti-Cal for adults and children. Estimates of the utilization rates, but are all generally low. There are strong indications that low reimbursement rates and cumbersome administrative requirements on providers result in low participation rates by providers. To the extent that the administrative changes in the bill improve provider participation, there could be increased utilization. For example, for every 5% increase in annual utilization by children, the cost would be about $35 million per year.
• Unknown potential cost-savings due to increased use of preventative dental services (General Fund and federal funds). Regular dental care, particularly for children, is likely to prevent dental conditions, such as cavities, from becoming more serious health problems that require more costly interventions later. To the extent that the bill results in increased utilization of preventative dental services in Denti-Cal, there are likely to be reduced costs for more serious dental services. Whether those avoided costs are greater than the cost of providing greater access to preventative services is unknown.

Background:

Under state and federal law, the Department of Health Care Services operates the Medi-Cal program, which provides health care coverage to low income individuals, families, and children. Medi-Cal provides coverage to childless adults and parents with household incomes up to 138% of the federal poverty level and to children with household incomes up to 266% of the federal poverty level. The federal government provides matching funds that vary from 50% to 90% of expenditures depending on the category of beneficiary.

Medi-Cal coverage includes full dental coverage for children and limited dental coverage for adults. (Adult coverage had been eliminated from the program in 2009 but was partially restored in 2013.) Dental services in Medi-Cal, referred to as Denti-Cal, are provided through the fee-for-service system in most of the state. Denti-Cal services are provided through dental managed care in Sacramento and Los Angeles Counties (enrollment in dental managed care is mandatory in Sacramento but optional in Los Angeles).

Recent analyses of the Denti-Cal program by the Bureau of State Audits and the Little Hoover Commission have found low levels of utilization (particularly by children), low provider reimbursement rates, and a complicated system for providers to navigate. Estimates of the annual usage vary. According to the Little Hoover Commission, in 2014 only 26% of eligible adults saw a dentist. According to the Department, 52% of eligible children saw a dentist in 2015. According to the federal government, 38% of eligible children saw a dentist in 2014.

Proposed Law:

AB 2207 would enact an number of changes to the operation of the Denti-Cal program, relating to provider enrollment, program monitoring, and reporting.

Specific provisions of the bill would:

• Require additional reporting of Denti-Cal performance measures, particularly reporting of provider-specific utilization measures;
• Require quarterly posting of Denti-Cal performance measures (rather than the current annual posting);
• Require expedited enrollment of Denti-Cal providers, for example by requiring a dental-specific enrollment form, pursuing automatic enrollment for providers who are already commercially credentialed with a Department of Health Care Services contractor (e.g. the state’s fiscal intermediary), and making other streamlining changes;
• Require the Department to disenroll a provider who has not submitted a claim for more than one year, with specific notification requirements;
• Require additional monitoring of access and utilization of Denti-Cal services;
• Require the Department to assess opportunities for payment reform proposals;
• Require the Department to consult with stakeholders on ways to improve the program, including several specific issues such as utilization controls and outreach activities;
• Require Medi-Cal managed care plans to provide dental screenings, make referrals for necessary dental care, and assist with referrals;
• Authorize the Department to initially implement the requirements of the bill without adopting regulations, but require implementing regulations to be adopted by December 31, 2018;
• Make implementation of the changes to the provider enrollment process and other actions to improve access to Denti-Cal contingent on federal approvals and receiving federal matching funds;
• Codify reporting requirements related to the Dental Transformation Initiative (a dental-specific program within the state’s new Medi-Cal 2020 waiver).

Related Legislation:

• SB 1098 (Canella) would establish a Denti-Cal Advisory Group within the Department of Health Care Services to study and oversee the policies and priorities of the Denti-Cal program. That bill is pending in the Assembly.
• AB 1051 (Maienschein) would require the Department of Health Care Services to increase certain Denti-Cal rates to those paid under commercial dental coverage. That bill will be heard in this committee.

Staff Comments:

The Department of Health Care Services has begun several of the activities required in the bill, such as reforms to the Denti-Cal provider enrollment system. The reporting requirements relating to the Dental Transformation Initiative are requirements of the Medi-Cal 2020 waiver and so would occur with or without this bill.

-- END --

SENATE COMMITTEE ON HEALTH

Senator Ed Hernandez, O.D., Chair

BILL NO: AB 2207

SUBJECT: Medi-Cal: dental program

SUMMARY:

Requires the Department of Health Care Services (DHCS) to expedite the Medi-Cal dental program (Denti-Cal) provider enrollment process, including an alternative automatic enrollment process for a provider already commercially enrolled, subject to federal approval. Requires automatic disenrollment of a dental provider who has not submitted a claim over a continuous 12-month period, after notice to the provider. Requires DHCS to monitor access and utilization of Denti-Cal services to assess opportunities to improve access and utilization. Expands and aligns Denti-Cal fee-for-service and Denti-Cal managed care annual reporting requirements, and requires quarterly data reporting requirements. Codifies the data reporting and evaluation requirements for the Dental Transformation Initiative in the state’s “Medi-Cal 2020” Section 1115 waiver.

Existing law:

1. Establishes the Medi-Cal program, which is administered by DHCS, under which qualified low-income individuals receive health care services, including certain dental services, as specified. Dental services are delivered through the fee-for-service (FFS) Denti-Cal program, except in Sacramento County, where enrollment in a dental managed care plan is required (with exceptions), and in Los Angeles County, where beneficiaries have the option to enroll in a dental managed care plan.
   
2. Requires DHCS to establish a list of performance measures to ensure the FFS Denti-Cal program meets quality and access criteria required by DHCS. Requires the performance measures to be designed to evaluate utilization, access, availability, and effectiveness of preventive care and treatment.
   
3. Requires DHCS to establish measures to monitor the dental FFS Denti-Cal program, and requires specific performance measures for children, and a more limited set of performance measures for adults.
   
4. Requires DHCS to establish a list of performance measures to ensure Denti-Cal dental health plans meet quality criteria required by DHCS. Requires the list to specify the benchmarks used by DHCS to determine whether and the extent to which a dental health plan meets each performance measure.
   

This bill:

1. Requires the FFS Denti-Cal performance measures for adults and children to include the total number of patients seen, on a per-provider basis, and the total number of preventive dental services, dental treatment services, and examinations and oral health evaluations rendered by each provider during each calendar year.
   
2. Requires quarterly (instead of annual) posting of the data of the Denti-Cal dental FFS and managed care program performance measures to be posted on DHCS’ Internet Web site, beginning April 1, 2017. Aligns the timing of the Denti-Cal FFS and managed care reports.
   
3. Requires DHCS to ensure, to the greatest degree possible, that the categories of data and performance measures selected for Denti-Cal FFS are consistent with the categories of data and performance measures selected for Denti-Cal managed care plans.
   
4. Requires DHCS to expedite the enrollment of Medi-Cal dental providers by streamlining the Medi-Cal provider enrollment process. Requires DHCS to pursue and implement all of the following activities, to the extent permitted by federal law:
   

a) Create a dental-specific enrollment form.

b) Pursue an alternative automatic enrollment process for a provider already commercially credentialed by either a dental FFS contractor or an administrative services contractor for the purpose of providing services as a commercial provider.

c) Discontinue requiring providers to resubmit an enrollment application that has been deemed incomplete if the missing information is available elsewhere within the application packet; and,

d) To publish the criteria for those processes in applicable provider bulletins and manuals, to the extent that DHCS expedites the enrollment of Medi-Cal dental providers by streamlining the Medi-Cal provider enrollment process.

1. Requires DHCS to maintain the provider network by disenrolling a billing and rendering provider who has not, over a continuous 12-month period, submitted a claim for reimbursement for services rendered.
   
2. Requires DHCS, prior to disenrolling a provider, to send a notice to the provider that the provider will be disenrolled from the dental program six months after the date of the notice. Prohibits DHCS from disenrolling a provider until six months after the date of that notice.
   
3. Requires DHCS, in order to improve the quality of the dental provider network, to also exercise additional measures as appropriate and permitted by law, including, but not limited to, temporary suspensions. Requires the parameters and criteria developed by DHCS for additional measures for disenrollments to be published in applicable provider bulletins and manuals.
   
4. Requires DHCS to monitor access and utilization of Medi-Cal dental services in the FFS and managed care delivery systems to assess opportunities to improve access and utilization.
5. Requires DHCS to assess opportunities to develop and implement innovative payment reform proposals within the Medi-Cal dental programs.
   
6. Requires DHCS to explore additional opportunities to improve the Medi-Cal Dental Program, in consultation with stakeholders and as deemed appropriate by the DHCS and to the extent permitted by federal law, including, but not limited to, the following:
   
7. Aligning the provision of dental anesthesia services with that of medical anesthesia services, including the ability to bill for applicable facility fees and ancillary services;
8. Adjusting other utilization controls for specialty services, as appropriate, to promote access to care while still protecting program integrity; and,
9. Expanding the scope of beneficiary outreach activities required by an entity that is contracted with DHCS to more broadly address underutilization throughout the state.
   
10. Requires DHCS, prior to implementing an action pursuant to 10) above, to post the proposed action on its Internet Web site at least 30 days before implementation.
    
11. Requires DHCS to work with Denti-Cal managed care plans that contract with DHCS to provide beneficiaries with access to dental plan liaisons to assist in the coordination of care for enrolled members.
    
12. Requires a Medi-Cal managed care health plan to do all of the following:
    
13. Provide dental screenings for every eligible beneficiary as a part of the beneficiary’s initial health assessment;
14. Ensure that an eligible beneficiary is referred to an appropriate Medi-Cal dental provider; and,
15. Identify plan liaisons available to dental managed care contractors and dental FFS contractors to assist with referrals to health plan covered services that may be needed by the beneficiary to aid in the treatment of an identified oral health care condition.
    
16. Exempts any contract amendment, modification, or change order to any contract entered into by DHCS for the purpose of implementing the state Medi-Cal Dental Program from specified provisions of the Public Contract and Government Codes, in addition to any policies, procedures, or regulations authorized by those provisions. Prohibits this provision from exempting DHCS from establishing a competitive bid process for awarding new fiscal intermediary contracts, as well as for awarding new Denti-Cal managed care contracts.
    
17. Requires DHCS, prior to implementing any change under this bill, to consult with, and provide notification to, stakeholders, including representatives from counties, local dental societies, nonprofit entities, legal aid entities, and other interested parties.
18. Requires DHCS to implement, interpret, or make specific policies and procedures pertaining to the dental FFS program and dental managed care plans, as well as applicable federal waivers and state plan amendments, including the provisions set forth in this bill, by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions without taking regulatory action, until regulations are adopted.
19. Requires DHCS, no later than December 31, 2018, to adopt regulations in accordance with the Administrative Procedures Act. Requires DHCS to provide a status report to the Legislature on a semiannual basis until regulations have been adopted beginning six months after the effective date of this bill.
20. Implements this bill only to the extent that DHCS obtains any federal approvals necessary to implement this bill and obtains federal matching funds to the extent permitted by federal law.
21. Codifies the Dental Transformation Initiative (DTI) data reporting and evaluation quality measure requirements required to be reported to the federal government and made publicly available for each of the four DTI domains contained in the Special Terms and Conditions (STCs) of Medi-Cal 2020, the state’s Section 1115 Medicaid waiver.

FISCAL EFFECT:

According to the Assembly Appropriations Committee:

1. DHCS states most activities required by this bill are simply aligning statute with their current contracts or current activities to improve Denti-Cal, and that this bill does not result in a direct staff cost increase. Despite this, the bill makes implementation of the bill's major provisions contingent on an appropriation for the specific purpose of its implementation.
2. This bill also contains a provision that could result in ongoing state cost pressure, namely the requirement that DHCS assess opportunities to improve access and utilization. Improving access and boosting utilization, however appropriate, is likely to have unknown, significant, ongoing costs for increased Denti-Cal services, likely offset to some extent by a reduction in costs to treat more serious dental disease (GF/federal).
3. This bill also requires DHCS to assess opportunities to implement innovative payment reform proposals, which are unlikely to result in a net ongoing cost increase, but could result in significant one-time development and implementation costs (GF/federal).

PRIOR VOTES:

COMMENTS:

1. Author’s statement. According to the author, dental care consistently ranks with the public as the most important type of health care after medical. The impact that good dental hygiene and health has on people’s self-esteem and quality of life cannot be understated. Dentistry is about prevention in order to avoid costly intervention at a later date; however, California’s system for participation and enrollment does not currently reflect that.

The Denti-Cal system is so broken that many dentists provide pro-bono care as opposed to taking Denti-Cal because they both give back to their community and society and manage it in a way that it is not financially devastating to their practices. The real loss in this system rests with beneficiaries. A 2014 California State Auditor report indicated that the insufficient number of dental providers willing to participate in Denti-Cal, low reimbursement rates, and a failure to adequately monitor the program, led to limited access to care and low utilization rates for Denti-Cal beneficiaries across the state. The Audit found that almost half of eligible beneficiaries did not receive dental care they were eligible for. Additionally, an April 2016 Little Hoover Commission (LHC) Report indicated that with dreadful reimbursement rates for dentists and slow, outdated paper-based administrative and billing processes that compare poorly with those of commercial insurers, Denti-Cal has thoroughly alienated its partners in the dental profession. Most California dentists want nothing to do with Denti-Cal and consequently, more than 13 million people eligible for coverage have limited or no access to dentists.

This is unacceptable, and we must take action to change the system. While the provisions in this bill seem modest, they are significant steps towards improving the Denti-Cal program. This measure will streamline the enrollment process for providers, ensure that provider networks are up-to-date so that beneficiaries can more easily access providers, improve coordination of care for beneficiaries, and increases DHCS oversight of the Denti-Cal program.

1. Medi-Cal has two different models for delivering dental services. The Medi-Cal Program is administered by DHCS and covers dental services for children under age 21 and a more limited benefit for adults. Adult dental coverage was eliminated in 2009 in AB 5 (Committee on Budget, Chapter 20, Statutes of 2009), which also eliminated other optional benefits for adults that had been covered under Medi-Cal. A more limited adult dental benefit was restored in AB 82 (Budget Committee, Chapter 23, Statutes of 2013), the 2013-14 budget health trailer bill.

Medi-Cal uses two different models for delivering dental services to children: FFS and Dental Managed Care:

1. FFS. In the FFS dental model, beneficiaries may receive dental services from any provider who accepts Medi-Cal payments and agrees to see them. Dental providers receive a payment for each service provided to the Medi-Cal beneficiary. FFS Denti-Cal expenditures are projected to be $1.05 billion total funds ($357.6 million GF) in 2016-17; and,
2. Denti-Cal managed care. In the dental managed care model, Medi-Cal pays dental plans a set amount per member per month (also known as a capitation rate) to provide dental care to beneficiaries enrolled in the plan. For most eligibles, the monthly per person rate is between $7.80 and $13.50 (monthly capitation rates are different for adults and children and refugees) for every Medi-Cal beneficiary enrolled in their plan. Generally, enrollees may only receive services from providers that are within the plan’s provider network.
   
   Only two counties have dental managed care. In Sacramento, almost all children and adults are mandatorily enrolled in a dental managed care plan. If a beneficiary does choose a dental managed care plan, the beneficiary will be automatically assigned to one. In Los Angeles County, beneficiaries may voluntarily enroll in a dental managed care plan. If a beneficiary in Los Angeles County does not choose to enroll in a dental managed care plan, they are automatically enrolled in FFS. Denti-Cal managed care expenditures are projected to be $166.8 million total funds ($65.7 million GF).

Denti-Cal utilization is low, with different estimates for different time frames. According to the Little Hoover Commission report, only 26% of eligible California adults with FFS Denti-Cal coverage saw a dentist in 2014, according to February 2016 DHCS data. DHCS stated that 51.8% of children 20 and under with Denti-Cal FFS coverage had a dental visit from October 2014 through September 2015. In December 2015, the Centers for Medicare and Medicaid Services (CMS), in approving the California Medi-Cal 2020 waiver, cited a figure of 37.8% of children 20 and under making a dental visit during the calendar year 2014. In December 2014, the California State Auditor cited CMS data to report that only 44% of California’s 5.1 million Denti-Cal-eligible children aged 20 and under saw a dentist from October 2012 through September 2013.

DHCS currently has a small workgroup effort regarding implementation of the Dental Transformation Initiative under the Medi-Cal 2020 Waiver. The purpose of this workgroup is to collaborate with DHCS on the planning and implementation efforts that are needed to ensure the success of the dental component of the waiver.

1. Dental provider enrollment. This bill requires DHCS to expedite the enrollment of Medi-Cal dental providers by streamlining the Medi-Cal provider enrollment process. To the extent allowed by federal law, DHCS would be required to:
   
2. Create a dental-specific enrollment form,
3. Pursue an alternative automatic enrollment process for a provider already commercially credentialed by either a dental FFS contractor or an administrative services contractor for the purpose of providing services as a commercial provider, and to
4. Discontinue requiring providers to resubmit an enrollment application that has been deemed incomplete if the missing information is available elsewhere within the application packet.

DHCS indicates Denti-Cal providers do not get enrolled through the Medi-Cal Provider Enrollment Division. Instead, dental providers use a paper application similar to the FFS Medi-Cal provider application, which DHCS indicates is very thorough and requires extensive review. Delta Dental handles Denti-Cal enrollment, and DHCS indicates the review is equally as thorough as the medical enrollment process. Prior to the introduction of this bill, Denti-Cal was evaluating the creation of a dental specific application because medical providers were moving toward on-line enrollment through PAVE, and many concerns had been raised to DHCS that the application questions may not pertain to dentists. In addition, because Delta Dental currently operates commercial dental coverage, it has can verify credentials and identify the dentists that serve in the commercial side who are also seeking Denti-Cal enrollment. DHCS indicates it has developed a revised paper application that will be going out shortly for stakeholder review, which will serve as an interim step before moving towards the use of PAVE for dental providers.

1. Denti-Cal rates. On July 1, 2016, DHCS released its statutorily required “Medi-Cal Dental Services Rate Review” in which it compared the reimbursement rates of Denti-Cal FFS’ 25 most utilized procedures to the same 25 procedure codes from other states’ Medicaid dental fee schedules. These 25 procedures made up approximately 85% of billed procedures in FY 2012-13 and FY 2013-14. California’s Denti-Cal FFS pays an average of 86.1% of Florida’s Medicaid Program’s dental fee schedule, 65.5% of Texas’, 75.4% of New York’s, and 129.2% of Illinois’ Medicaid Program’s dental fee index. The report found that Denti-Cal paid, on average, 28.3% of commercial rates in the Pacific Area in 2013-14.
2. Dental Transformation Initiative of Medi-Cal Section 1115 Waiver. The DTI is a new feature of Medi-Cal 2020, the state’s most recent Section 1115 waiver. It is funded at $750 million total funds ($375 million in federal funds) generated from federal waiver funding drawn down for Designated State Health Programs. Of this amount, $10 million in total funds is contingent upon the state meeting statewide metrics. AB 1568 (Bonta and Atkins) would codify the DTI provisions of the Special Terms and Conditions of the waiver. DTI consists of four domain areas as follows:
3. Domain 1: Increase Preventive Services Utilization for Children;
4. Domain 2: Caries Risk Assessment and Disease Management;
5. Domain 3: Increase Continuity of Care; and,
6. Domain 4: Local Dental Pilot Programs.

This bill would codify the STCs provisions regarding DHCS reporting DTI data and quality measures. Under the STCs, this information is required to be sent to the federal Centers for Medicare and Medicaid Services and made publicly available.

1. Related legislation.
2. SB 1098 (Cannella) establishes in DHCS the 13-member Denti-Cal Advisory Group (Advisory Group), and specifies the duties of the advisory group to include studying the policies and priorities of Denti-Cal with the goal of raising the Denti-Cal utilization rate among eligible child beneficiaries to 60% or greater and providing assistance and advice to DHCS, the Legislature, and the Governor regarding proposed decisions relating to the Denti-Cal program to ensure that those decisions are based on the best available evidence. SB 1098 is in the Assembly Health Committee.
   
3. AB 1051 (Maienschein) appropriates $200 million from the GF to DHCS for the Denti-Cal program. DHCS would be required to allocate the funds to increase reimbursement rates for the 15 most common prevention, treatment, and oral evaluation services to the Medicaid national average, and to increase funding for preventative care and case management services, as appropriate, to achieve significant long-term cost savings, increased provider participation, and increased beneficiary utilization under Denti-Cal. AB 1051 is in the Senate Health Committee and is scheduled for hearing on June 29, 2016.
4. AB 1586 (Bonta and Atkins) and SB 815 (Hernandez and De Leon) are companion urgency bills to enact specified statutory provisions of “Medi-Cal 2020,” the state’s recently approved five-year federal Section 1115 waiver, which runs through December 31, 2020. AB 1586 includes the DTI, the Whole Person Care program and the evaluations required under the Special Terms of Conditions (STCs) of Medi-Cal 2020, and requires DHCS to conduct or arrange to have conducted studies, reports and assessments required under the STCs. SB 815 (Hernandez and De Leon) contains the provisions implementing the Global Payment Program and the Public Hospital Redesign Incentive Program and the access assessment requirements. SB 815 passed out of the Assembly Appropriations Committee on June 15, 2016 and AB 1568 is scheduled to be heard in the Senate Appropriations Committee on June 20, 2016.
5. Prior legislation. SB 694 (Padilla of 2011-12), would have established the Statewide Office of Oral Health (Office) within the Department of Public Health and authorized the Office to conduct a study to assess the safety, quality, cost-effectiveness, and patient satisfaction of expanded dental procedures performed by specified dental health care providers. SB 694 was held on the Assembly Appropriations Committee suspense file.

AB 82 (Committee on Budget, Chapter 23, Statutes of 2013), restored partial adult optional dental benefits, including full mouth dentures, effective May 1, 2014. The fiscal impact of the restoration is $183.8 million for 2015-16 and $339.9 million for 2016-17.

SB 75 (Committee on Budget and Fiscal Review, Chapter 18, Statutes of 2015), the health budget trailer bill of 2015, exempted FFS and dental managed care dental services and applicable ancillary services for dates of service on or after July 1, 2015, or the effective date of any necessary federal approvals, whichever is later from the 10% Denti-Cal rate reduction. The total funds cost for this change is $105 million.

1. Support. The Little Hoover Commission (LHC), in its 2016 report, Fixing Denti-Cal, found the program to be lacking in multiple areas. The LHC made several recommendations aimed at expanding access to Denti-Cal services, with an ultimate goal of 66% of Denti-Cal-eligible children making annual dental visits. Several of those recommendations would require DHCS to take administrative actions to improve Denti-Cal. This bill would call on DHCS to expedite provider enrollment by creating a dental-specific enrollment form and pursuing alternative automatic enrollment for dentists already established commercially. This bill would also require DHCS to monitor access and utilization and explore additional opportunities to improve Denti-Cal. The LHC indicates it supports this bill because it requires DHCS to improve and expand Denti-Cal provider enrollment, and shares the LHC’s overall goal of expanding access to care.
   

The County Health Executives Association of California state that this bill proposes modest changes to the program, including expediting dental provider enrollment into the Medi-Cal program, ensuring screenings are provided for every eligible Medi-Cal beneficiary as part of their initial health assessment, and ensuring beneficiaries are referred to appropriate Medi-Cal dental providers, which could improve the delivery of dental services to those most in need in California.

1. Proposed author’s amendments. The author is proposing amendments to address concerns amendments requested by several stakeholder groups. These changes include three changes requested by Western Center on Law and Poverty to broaden the Denti-Cal performance measures for adults to align those measures with the measures for children, to require DHCS to “continuously” maintain the Denti-Cal provider network, and to include an annual review of the Denti-Cal Treatment Authorization Review process as part of DHCS’ requirement under this bill to monitor access and utilization. In addition, the author’s proposed amendments include a request by health plans to clarify the scope of the requirement in this bill that Medi-Cal managed care plans identify plan liaisons available to dental managed care and FFS contractors. This amendment would delete language in the requiring health plans to assist with referrals “that may be needed by the beneficiary to aid in the treatment of an identified oral health care condition.” Finally, the author is proposing amendments to add the number of applications of fluoride varnishes and the number of beneficiaries requiring general anesthesia to the list of Denti-Cal performance measures.

10) Clarifying amendments. To clarify the Denti-Cal FFS child and adult performance measure monitoring requirements changes made by this bill, staff recommends these provisions be re-worded to clarify which provisions are required to be reported in aggregate versus on a per dental provider basis.

SUPPORT AND OPPOSITION:

Support: California Coverage and Health Initiatives

California Dental Association

California Pan-Ethnic Health Network

California Primary Care Association

Children Now

Children’s Defense Fund-California

Children’s Partnership

County Health Executives Association of California

First 5 Association of California

National Association of Social Workers, California Chapter

Nurse-Family Partnership

The Little Hoover Commission

Oppose: None received

-- END --

ASSEMBLY THIRD READING

ATR Bill Id:

Author:(Wood)

As Amended Ver:April 26, 2016

Majority vote

SUMMARY: Makes changes to the Medi-Cal dental program (Denti-Cal) provider enrollment and disenrollment process, increases access and utilization oversight responsibility of the Department of Health Care Services (DHCS) over Denti-Cal contracts, and aligns Denti-Cal fee-for-service (FFS) and Dental managed care (DMC) annual and quarterly data reporting requirements. Specifically, this bill:

1. Requires DHCS to expedite the enrollment of Denti-Cal providers by streamlining the Medi-Cal provider enrollment process by creating a dental-specific enrollment form, pursuing an alternative automatic enrollment process for a provider already commercially credentialed, and other activities, as specified;
2. Requires DHCS to disenroll a provider who has not participated in the dental program, as determined by DHCS, for more than a continuous one-year period. Permits DHCS to exercise additional measures as appropriate in order to improve the quality of the dental provider network, including, but not limited to, temporary suspensions.
3. Requires DHCS to monitor access and utilization of Denti-Cal services in the FFS and DMC delivery systems to assess opportunities to improve access and utilization and assess opportunities to develop and implement innovative payment reform proposals within Denti-Cal.
4. Requires DHCS to explore additional opportunities in consultation with stakeholders, to improve the Denti-Cal, as specified;
5. Allows DHCS to implement, interpret, or make specific policies and procedures by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions, requires DHCS to thereafter adopt regulations, and requires DHCS to update the legislature until regulations are adopted.
6. Makes implementation of most of its provisions contingent upon federal approval, availability of federal matching funds, and an appropriation in the annual Budget Act each fiscal year for the specific purpose of implementation.
7. Contains other provisions to improve Denti-Cal accountability, transparency, and quality.

FISCAL EFFECT: According to the Assembly Appropriations Committee:

1. DHCS states most activities required by this bill are simply aligning statute with their current contracts or current activities to improve Denti-Cal, and that this bill does not result in a direct staff cost increase. Despite this, the bill makes implementation of the bill's major provisions contingent on an appropriation for the specific purpose of its implementation.
2. This bill also contains a provision that could result in ongoing state cost pressure, namely the requirement that DHCS assess opportunities to improve access and utilization. Improving access and boosting utilization, however appropriate, is likely to have unknown, significant, ongoing costs for increased Denti-Cal services, likely offset to some extent by a reduction in costs to treat more serious dental disease (General Fund (GF)/federal funds).
3. This bill also requires DHCS to assess opportunities to implement innovative payment reform proposals, which are unlikely to result in a net ongoing cost increase, but could result in significant one-time development and implementation costs (GF/federal funds).

COMMENTS: According to the author, dental care consistently ranks with the public as the most important type of health care after medical. The impact that good dental hygiene and health has on people's self-esteem and quality of life cannot be understated. Dentistry is about prevention in order to avoid costly intervention at a later date; however, our system for participation and enrollment does not currently reflect that. Participation and entry to the program as a participating provider should be easy with restrictions and limiting parameters put in place only when a dentist's pattern of behavior warrants such. The limited number of private practitioners able to participate in the program is concerning due to the geographic limitations this can create. There are counties in California with just a couple of dentists participating in the program and too often these are older dentists who will be retiring soon, with no dentists able to take their place.

The author states that the Denti-Cal system is so broken that many dentists provide pro-bono care as opposed to taking Denti-Cal because they both give back to their community and society and manage it in a way that it is not financially devastating to their practices. The real loss in this system rests with beneficiaries.

Denti-Cal. States are federally required to provide dental benefits to children covered by Medicaid (Medi-Cal in California) and the Children's Health Insurance Program. Denti-Cal is the Medicaid program that provides comprehensive dental care to pediatric and pregnant Medi-Cal beneficiaries and limited emergency services to adult beneficiaries. While Medicaid covers dental services for all child enrollees as part of a comprehensive set of benefits, referred to as the Early and Periodic Screening, Diagnostic and Treatment benefit, states may choose whether to provide dental benefits for adults. Minimum federal requirements for pediatric dental Medicaid programs include relief of pain and infections, restoration of teeth and maintenance of dental health. For children in Medi-Cal, dental care is provided on a FFS basis in all counties, with Sacramento and Los Angeles Counties also offering services through DMC plans.

For more than 40 years Medicaid-enrolled Californians of any age were eligible for basic diagnostic, preventive, restorative and emergency dental procedures provided by participating dentists through Denti-Cal. In 2007, Denti-Cal provided comprehensive oral health care to more than eight million people. However, from July 2009 to May 2014, California eliminated funding for most adult non-emergency Denti-Cal benefits, effectively eliminating California's oral health safety-net. A partial restoration of benefits, primarily diagnostic and preventative services, was enacted in the 2013 Budget Act and became effective May 1, 2014.

Office of Inspector General Report. In January 2016, the federal Department of Health and Human Services Officer of the Inspector General (OIG) published a report titled "Most Children with Medicaid in Four States are Not Receiving Required Dental Services." The study focused on four states: California, Indiana, Louisiana, and Maryland and analyzed Medicaid dental claims with service dates in 2011 and 2012, beneficiary enrollment files, and conducted structured interviews with state officials. The OIG report found that three out of four children did not receive all required dental services, with one in four children failing to see a dentist at all. All four states reported that they do not routinely track whether children are receiving all the required services. In addition, two of the four states had policies that do not allow payment for particular services in accordance with their periodicity schedules. All states reviewed reported facing shortages of participating dental providers and challenges in educating families about the importance of regular dental care.

State Auditor's Report. On December 11, 2014, the California State Auditor issued a report titled "California Department of Health Care Services: Weaknesses in Its Denti-Cal Limit Children's Access to Dental Care." The report stated that insufficient number of dental providers willing to participate in Medi-Cal, low reimbursement rates and a failure to adequately monitor the program, led to limited access to care and low utilization rates for Medi-Cal beneficiaries across the state. The Audit found that 16 counties either have no active providers or do not have providers willing to accept new Medi-Cal patients, and 16 other counties have an insufficient number of providers. Recent changes in federal and state laws that have expanded Medi-Cal coverage could increase the number of children and adults who can receive additional covered dental services from 2.7 million to as many as 6.4 million, bringing into question the state's ability to provide timely and adequate care to beneficiaries.

Little Hoover Commission (LHC) Report. On April 1, 2016, the LHC published a report titled "Fixing Denti-Cal." The LHC initiated an examination of the state's Denti-Cal program after receiving formal requests for a review from Legislators in April of 2015 and following the findings of the 2014 State Auditor's Report. Lawmakers requested that the LHC "undertake a review of the Denti-Cal program and identify the necessary steps to assure this vital program meets its purpose to provide access to dental care for many of the most vulnerable Californians including children." The LHC Report highlighted the lack of providers in the Denti-Cal program, inadequate and low provider reimbursement rates, enrollment, billing, and administrative challenges.

Analysis Prepared by: Paula Villescaz / HEALTH / (916) 319-2097 FN: 0003288

Date of Hearing: May 11, 2016

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Lorena Gonzalez, Chair

ABPCA Bill Id:AB 2207

Author:(Wood) – As Amended Ver:April 26, 2016

Urgency: No State Mandated Local Program: No Reimbursable: No

SUMMARY:

This bill makes a number of changes to the Department of Health Care Service's (DHCS's) administration of the Medi-Cal dental program (Denti-Cal). Specifically, this bill:

1. Requires DHCS to expedite the enrollment of Denti-Cal providers by streamlining the provider enrollment process through a dental-specific enrollment form, implementing automated enrollment processes for credentialed dentists, and implementing other processes.
2. Requires DHCS to monitor access and utilization of Denti-Cal services in the fee-for-service (FFS) and Dental managed care (DMC) delivery systems, and to assess opportunities to improve access and utilization, as well as to assess opportunities to develop and implement innovative payment reform proposals within Denti-Cal.
3. Requires DHCS to explore additional opportunities, in consultation with stakeholders, to improve the Denti-Cal program.
4. Requires a Medi-Cal managed care health plan to perform certain activities, including providing dental screening as part of a beneficiary's initial health assessment, ensure that an eligible beneficiary is referred to an appropriate dental provider; and identify plan liaisons available to DMC contractors and dental FFS contractors to assist in coordination of care.
5. Requires DHCS to consult with and provide notification to specified stakeholders prior to implementation of new requirements.
6. Allows DHCS to implement, interpret, or make specific policies and procedures by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions, requires DHCS to thereafter adopt regulations, and requires DHCS to update the legislature until regulations are adopted.
7. Makes implementation of most of its provisions contingent upon federal approval, availability of federal matching funds, and an appropriation in the annual Budget Act each fiscal year for the specific purpose of implementation.
8. Contains other provisions to improve Denti-Cal accountability, transparency, and quality.

FISCAL EFFECT:

1. DHCS states most activities required by this bill are simply aligning statute with their current contracts or current activities to improve Denti-Cal, and that this bill does not result in a direct staff cost increase. Despite this, the bill makes implementation of the bill's major provisions contingent on an appropriation for the specific purpose of its implementation.
2. This bill also contains a provision that could result in ongoing state cost pressure, namely the requirement that DHCS assess opportunities to improve access and utilization. Improving access and boosting utilization, however appropriate, is likely to have unknown, significant, ongoing costs for increased Denti-Cal services, likely offset to some extent by a reduction in costs to treat more serious dental disease (GF/federal).
3. This bill also requires DHCS to assess opportunities to implement innovative payment reform proposals, which are unlikely to result in a net ongoing cost increase, but could result in significant one-time development and implementation costs (GF/federal).

COMMENTS:

1. Purpose. According to the author, this bill is responsive to recent reports that have detailed significant problems in Denti-Cal. The author states this measure will make modest changes to streamline enrollment of providers, ensure provider networks are up-to-date so beneficiaries can find providers, improve coordination of care, and increase DHCS oversight of the Denti-Cal program.
2. Background. A 2014 California State Auditor report indicated Denti-Cal was plagued by an insufficient number of dental providers willing to participate in the program, low reimbursement rates, and a failure to adequately monitor access and utilization. According to the auditor, limited access to care resulted in low utilization rates for Denti-Cal beneficiaries across the state. The audit found almost half of eligible beneficiaries did not receive any dental care. Additionally, an April 2016 Little Hoover Commission report stated, "With dreadful reimbursement rates for dentists and slow, outdated paper-based administrative and billing processes that compare poorly with those of commercial insurers, Denti-Cal has thoroughly alienated its partners in the dental profession." The report also notes millions eligible for Denti-Cal coverage have limited or no access to dentists. This bill codifies a number of improvements to which DHCS has committed, in order to respond to the identified problems.
3. Staff Comment. According to DHCS, this bill should not result in direct increase in costs, as it aligns with current activities. Thus, the provision making implementation of a number of the bill's major provisions contingent on an annual budget appropriation should be deleted.

Analysis Prepared by: Lisa Murawski / APPR. / (916) 319-2081

Date of Hearing: April 19, 2016

ASSEMBLY COMMITTEE ON HEALTH

Jim Wood, Chair

ABPCA Bill Id:AB 2207

Author:(Wood) – As Introduced Ver:February 18, 2016

SUBJECT: Medi-Cal: dental program.

SUMMARY: Makes changes to the Medi-Cal dental program (Denti-Cal) provider enrollment and disenrollment process, increases access and utilization oversight responsibility of the Department of Health Care Services (DHCS) over Denti-Cal contracts, and aligns Denti-Cal fee-for-service (FFS) and Dental managed care (DMC) annual and quarterly data reporting requirements. Specifically, this bill:

1. Requires DHCS to expedite the enrollment of Denti-Cal providers by streamlining the Medi-Cal provider enrollment process through the following activities:
   1. Create a dental-specific enrollment form;
   2. Pursue an alternative automatic enrollment process for a provider already commercially credentialed by either a dental FFS contractor or an administrative services contractor for the purpose of providing services as a commercial provider;
   3. Discontinue requiring providers to resubmit an enrollment application that has been deemed incomplete if the missing information is available elsewhere within the application packet; and,
   4. Require DHCS to publish the criteria to expedite the enrollment of Denti-Cal providers in applicable provider bulletins and manuals.
2. Requires DHCS to disenroll a provider who has not participated in the dental program, as determined by DHCS, for more than a continuous one-year period. Permits DHCS to exercise additional measures as appropriate in order to improve the quality of the dental provider network, including, but not limited to, temporary suspensions.
3. Requires DHCS to monitor access and utilization of Denti-Cal services in the FFS and DMC delivery systems to assess opportunities to improve access and utilization and assess opportunities to develop and implement innovative payment reform proposals within Denti-Cal.
4. Requires DHCS to explore additional opportunities in consultation with stakeholders, to improve the Denti-Cal, including, but not limited to, the following:
   1. Aligning the provision of dental anesthesia services with that of medical anesthesia services, including the ability to bill for applicable facility fees and ancillary services;
   2. Adjusting other utilization controls for specialty services, as appropriate, to promote access to care while still protecting program integrity; and,
   3. Expanding the scope of beneficiary outreach activities required by an entity that is contracted with the department to more broadly address underutilization throughout the state.
5. Requires DHCS to work with DMC plans that contract with DHCS for the purposes of implementing the Denti-Cal to provide beneficiaries with access to plan liaisons to assist in the coordination of care for enrolled members.
6. Requires a Medi-Cal managed care health plan to do all of the following:
   1. Provide dental screenings for every eligible beneficiary as a part of the beneficiary’s initial health assessment;
   2. Ensure that an eligible beneficiary is referred to an appropriate Medi-Cal dental provider; and,
   3. Identify plan liaisons available to DMC contractors and dental FFS contractors to assist in coordination of care.
7. Requires DHCS to post any proposed action on its Internet Website at least 30 days prior to implementing an action as required in 6) above.
8. Exempts any amendments, modifications or changes to Denti-Cal contracts entered into by DHCS from certain contracting provisions in order to increase the efficiency and timeliness of changes. Specifies that these exemptions do not exempt DHCS from establishing a competitive bid process for awarding new Denti-Cal contracts.
9. Requires DHCS to consult with, and provide notification to, stakeholders, including representatives from counties, local dental societies, nonprofit entities, legal aid entities, and other interested parties prior to implementation of new requirements.
10. Permits DHCS to implement, interpret, or make specific policies and procedures pertaining to the dental FFS program and DMC plans, as well as applicable federal waivers and state plan amendments, by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions until regulations are adopted. Requires thereafter DHCS to adopt regulations in accordance with the requirements of the Administrative Procedures Act.
11. Requires DHCS to provide a status report to the Legislature six months after the effective date of the statute and on a semiannual basis thereafter until regulations have been adopted.
12. Makes the implementation of this bill conditional upon DHCS obtaining any federal approvals necessary, any federal matching funds to the extent permitted by federal law, and an appropriation in the annual Budget Act each fiscal year.
13. Requires the list of performance measures established by DHCS along with the data of the dental FFS program to be posted on the department’s Internet Website commencing January 31, 2017, for the 2015-16 fiscal year, and annually on or before January 31 each year thereafter.
14. Requires DHCS to post dental FFS performance data on a quarterly basis commencing April 30, 2017 on their Internet Website.

EXISTING LAW:

1. Requires DHCS to establish a list of performance measures designed to evaluate utilization, access, availability, and effectiveness of preventive care and treatment to ensure the dental FFS program meets quality and access criteria created by DHCS after consultation with key stakeholders as specified.
2. Requires DHCS to prepare, on an annual basis, a summary report of the nature and types of complaints and grievances regarding access to, and quality of, dental services, including the outcome and requires the report to be posted on their Internet Website.
3. Requires DHCS to establish a list of performance measures to ensure dental health plans meet quality criteria required by DHCS including but not be limited to provider network adequacy, overall utilization of dental services, annual dental visits, use of preventive dental services, use of dental treatment services, use of examinations and oral health evaluations, and other measures as specified.
4. Requires the performance measures to specify the benchmarks used by DHCS to determine whether and the extent to which a dental health plan meets each performance measure. Requires the Department of Managed Health Care (DMHC) and the DHCS stakeholder advisory committee to have access to all performance measures and benchmarks used by DHCS.
5. Requires that the survey of member satisfaction with plans and providers be the same dental version of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey as used by the previously established Healthy Families Program.
6. Requires DHCS to notify dental health plans at least 30 days prior to the implementation date of performance measures and requires DHCS to include the initial list of performance measures and benchmarks in any dental health contracts entered into between the department and a dental health plan.
7. Requires DHCS to update performance measures and benchmarks and establish additional performance measures and benchmarks, as specified.
8. Requires DHCS to, when evaluating performance measures and benchmarks for retention on, addition to, or deletion from the list, consider all of the following criteria:
   1. Monthly, quarterly, annual, and multiyear DMC trended data;
   2. County and statewide Medi-Cal dental FFS performance and quality ratings;
   3. Other state and national dental program performance and quality measures; and,
   4. Other state and national performance ratings.
9. When establishing and updating the performance measures and benchmarks, requires DHCS to consult the existing managed care stakeholder advisory committee well as dental health plan representatives and other stakeholders, including representatives from counties, local dental societies, nonprofit entities, legal aid entities, and other interested parties.
10. Requires, when evaluating a dental health plan’s ability to meet the criteria established through the performance measures and benchmarks, DHCS to select specific performance measures as the basis for establishing financial or other incentives or disincentives, including, but not limited to, bonuses, payment withholds, and adjustments to beneficiary assignment to plan algorithms.
11. Requires DHCS to designate an external quality review organization (EQRO) to conduct external quality reviews for any dental health plan contracting with DHCS.
12. Requires dental health plans, at least annually, to arrange for an external quality of care review with the EQRO designated by DHCS that evaluates the dental health plan’s performance in meeting the performance measures, as specified. Permits DMHC direct access to all external quality of care review information upon request to DHCS.
13. Requires all marketing methods and activities to be used by dental plans to be in compliance with state regulations and requires each dental plan to submit its marketing plan to DHCS for review and approval.
14. Requires each dental plan to submit its member services procedures, beneficiary informational materials, and any updates to those procedures or materials to DHCS for review and approval. Requires DHCS to ensure that member services procedures and beneficiary informational materials are clear and provide timely and fair processes for accepting and acting upon complaints, grievances, and disenrollment requests, including procedures for appealing decisions regarding coverage or benefits.
15. Requires each dental plan to submit its provider compensation agreements to DHCS for review and approval.
16. Requires DHCS to post to its Internet Website a copy of all final reports completed by DMHC dental managed care plans.

FISCAL EFFECT: This bill has not yet been analyzed by a fiscal committee.

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, dental care consistently ranks with the public as the most important type of health care after medical. The impact that good dental hygiene and health has on people’s self-esteem and quality of life cannot be understated. Dentistry is about prevention in order to avoid costly intervention at a later date; however, our system for participation and enrollment does not currently reflect that. Participation and entry to the program as a participating provider should be easy with restrictions and limiting parameters put in place only when a dentist’s pattern of behavior warrants such. The limited number of private practitioners able to participate in the program is concerning due to the geographic limitations this can create. There are counties in California with just a couple of dentists participating in the program and too often these are older dentists who will be retiring soon, with no dentists able to take their place.

The author states that the Denti-Cal system is so broken that many dentists provide pro-bono care as opposed to taking Denti-Cal because they both give back to their community and society and manage it in a way that it is not financially devastating to their practices. The real loss in this system rests with beneficiaries. A 2014 California State Auditor report indicated that the insufficient number of dental providers willing to participate in Denti-Cal, low reimbursement rates, and a failure to adequately monitor the program, led to limited access to care and low utilization rates for Denti-Cal beneficiaries across the state. The Audit found that almost half of eligible beneficiaries did not receive dental care they were eligible for. Additionally, an April 2016 Little Hoover Commission (LHC) Report indicated that with dreadful reimbursement rates for dentists and slow, outdated paper-based administrative and billing processes that compare poorly with those of commercial insurers, Denti-Cal has thoroughly alienated its partners in the dental profession. Most California dentists want nothing to do with Denti-Cal and consequently, more than 13 million people eligible for coverage have limited or no access to dentists.

This is unacceptable, and we must take action to change the system. While the provisions in this bill seem modest, they are significant steps towards improving the Denti-Cal system. The author concludes that this measure will streamline the enrollment process for providers, ensure that provider networks are up-to-date so that beneficiaries can more easily access providers, improve coordination of care for beneficiaries, and increase DHCS oversight of the Denti-Cal program.

1. BACKGROUND.
   1. Denti-Cal. States are federally required to provide dental benefits to children covered by Medicaid (Medi-Cal in California) and the Children's Health Insurance Program. Denti-Cal is the Medicaid program that provides comprehensive dental care to pediatric and pregnant Medi-Cal beneficiaries and limited emergency services to adult beneficiaries. While Medicaid covers dental services for all child enrollees as part of a comprehensive set of benefits, referred to as the Early and Periodic Screening, Diagnostic and Treatment benefit, states may choose whether to provide dental benefits for adults. Minimum federal requirements for pediatric dental Medicaid programs include relief of pain and infections, restoration of teeth and maintenance of dental health. For children in Medi-Cal, dental care is provided on a FFS basis in all counties, with Sacramento and Los Angeles Counties also offering services through DMC plans.

For more than 40 years Medicaid-enrolled Californians of any age were eligible for basic diagnostic, preventive, restorative and emergency dental procedures provided by participating dentists through Denti-Cal. In 2007, Denti-Cal provided comprehensive oral health care to more than eight million people. However, from July 2009 to May 2014, California eliminated funding for most adult non-emergency Denti-Cal benefits, effectively eliminating California’s oral health safety-net. A partial restoration of benefits, primarily diagnostic and preventative services, was enacted in the 2013 Budget Act and became effective May 1, 2014.

• 1. Denti-Cal FFS Performance. In 2012, dental health plans contracted with Barbara Aved Associates to conduct research on Medi-Cal’s FFS dental care. The study found, in part, that: i) 97% of non-participating dentists cited low reimbursement rates as the reason for not participating; ii) 90% of general dentists said it was somewhat or very difficult to find a pediatric dentists accepting Medi-Cal referrals; and, iii) 38% of general dentists and 69% of pediatric dentists who take Medi-Cal have 15% or less of their patient population in Medi-Cal. The researcher concluded that children in Medi-Cal are getting inadequate dental care, largely due to insufficient provider participation, reflecting low reimbursement rates. The researcher recommended: i) streamlining the provider enrollment process; ii) increasing rates; iii) adopting more quality measures; iv) increasing monitoring of utilization data; and, v) increasing public oral health education to families
  2. Denti-Cal Managed Care Performance. Under the FFS model, providers are reimbursed according to a rate schedule set by DHCS. The Medi-Cal Dental Managed Care Program contracts with three Geographic Managed Care (GMC) Plans and five Prepaid Health Plans that provide dental services to enrolled beneficiaries. Each dental plan receives a negotiated monthly per capita rate from the state for every recipient enrolled in their plan. Medi-Cal beneficiaries residing in Los Angeles County can access dental care either through the FFS delivery system or through prepaid health plans, while Medi-Cal beneficiaries residing in Sacramento County (with the exception of specific populations) are mandatorily enrolled in prepaid health plans for dental care. If Sacramento County beneficiaries are unable to secure services through their prepaid health plan in accordance with the applicable contractual time frames and the Knox-Keene Health Care Service Plan Act of 1975, they can qualify for the beneficiary dental exemption, which allows them to move into the FFS delivery system. In 2012, about 143,000 child beneficiaries received services under the DMC plans operating in the counties of Los Angeles and Sacramento. In 2010, First 5 of Sacramento commissioned the “Sacramento Deserves Better” report, produced by Barbara Aved Associates, which analyzed access, utilization, and quality of dental care under Sacramento’s GMC Dental Services model. Key findings from this report include the following:
     1. Only 20% of children in GMC dental services used a dental service in 2008, as compared to over 40% of children in Medi-Cal statewide who are predominately in FFS;
     2. Only 30% of children in GMC dental services received a dental service in 2010;
     3. Sacramento GMC dental services is consistently one of the lowest-ranking counties for Medi-Cal dental access in the entire state;
     4. Dental plans have not complied with a “first tooth/first birthday” recommendation for the initial dental visit;
     5. Inadequate prevention services were provided; and,
     6. The state provided minimal oversight of GMC dental services contracts.

Early in 2012, through a series of articles and editorials, the Sacramento Bee (Bee) brought attention to the dire conditions of Sacramento County’s pediatric DMC program. The Bee coverage focused on the findings of the report commissioned by First 5 of Sacramento, which revealed shockingly low utilization rates and highlighted a series of examples of specific children who had been in desperate need of dental care, yet unable to access the care they needed without significant delays, worsening conditions, prolonged pain, and a significant amount of fear, frustration, and relentless advocacy on the part of their parents.

• 1. Legislative Hearings. A series of legislative hearings in 2012 found a lack of oversight of the DMC programs in Sacramento and Los Angeles counties by DHCS, resulting in significant underutilization by pediatric beneficiaries. On March 8, 2012, the Assembly Select Committee on Workforce and Access to Care convened a meeting to examine the state of the dental safety net, followed by a Senate Budget Hearing on March 22, 2012, that directly examined the Sacramento GMC dental program. As a result, 2012 budget trailer bill provided for the beneficiary dental exemption process, which allows beneficiaries who are not receiving adequate or timely access to care to opt out of the GMC dental program, requires DHCS to establish performance measures and benchmarks for dental health plans, requires DHCS to utilize dental health plan performance data for contracting purposes, and requires the establishment of contract incentives and disincentives, along with enacting other oversight mechanisms.
  2. Office of Inspector General Report. In January 2016, the federal Department of Health and Human Services Officer of the Inspector General (OIG) published a report titled “Most Children with Medicaid in Four States are Not Receiving Required Dental Services.” The study focused on four states: California, Indiana, Louisiana, and Maryland and analyzed Medicaid dental claims with service dates in 2011 and 2012, beneficiary enrollment files, and conducted structured interviews with state officials. The OIG report found that three out of four children did not receive all required dental services, with one in four children failing to see a dentist at all. All four states reported that they do not routinely track whether children are receiving all the required services. In addition, two of the four states had policies that do not allow payment for particular services in accordance with their periodicity schedules. All states reviewed reported facing shortages of participating dental providers and challenges in educating families about the importance of regular dental care.
  3. State Auditor's Report. On December 11, 2014, the California State Auditor issued a report titled “California Department of Health Care Services: Weaknesses in Its Denti-Cal Limit Children's Access to Dental Care." The report stated that insufficient number of dental providers willing to participate in Medi-Cal, low reimbursement rates and a failure to adequately monitor the program, led to limited access to care and low utilization rates for Medi-Cal beneficiaries across the state. The Audit found that 16 counties either have no active providers or do not have providers willing to accept new Medi-Cal patients, and 16 other counties have an insufficient number of providers. Recent changes in federal and state laws that have expanded Medi-Cal coverage could increase the number of children and adults who can receive additional covered dental services from 2.7 million to as many as 6.4 million, bringing into question the state's ability to provide timely and adequate care to beneficiaries.
  4. LHC Report. On April 1, 2016, the LHC published a report titled “Fixing Denti-Cal." The LHC initiated an examination of the state’s Denti-Cal program after receiving formal requests for a review from Legislators in April of 2015 and following the findings of the 2014 State Auditor’s Report. Lawmakers requested that the LHC “undertake a review of the Denti-Cal program and identify the necessary steps to assure this vital program meets its purpose to provide access to dental care for many of the most vulnerable Californians including children.” The LHC Report highlighted the lack of providers in the Denti-Cal program, inadequate and low provider reimbursement rates, enrollment, billing, and administrative challenges. The LHC provided 11 recommendations on how to improve the Denti-Cal program, as follows:
     1. The Legislature should set a target of 66% of children with Denti-Cal coverage making annual dental visits;
     2. DHCS should simplify the Denti-cal provider enrollment forms and put them online in 2017;
     3. DHCS should overhaul the process of treatment authorization requests;
     4. DHCS should implement a customer focused program to improve relationships with its providers;
     5. DHCS should purge outdated regulations;
     6. The Legislature and Governor should enact and sign legislation in 2016 to create an evidence-based advisory group for the Denti-Cal program;
     7. The Legislature and Governor should fund a statewide expansion of teledentistry and the virtual dental home;
     8. State government, funders, and non-profits should lead a sustained statewide “game changer” to reorient the oral health care system for Denti-Cal beneficiaries toward preventative care;
     9. The Legislature and DHCS should expand the concepts of Washington State’s Access to Baby and Child Dentistry program and Alameda County’s Healthy Kids, Healthy Teeth program to more regions of California;
     10. DHCS and California counties should steer more Denti-Cal eligible patients into Federally Qualified Health Centers with capacity to see them; and,
     11. Medical societies and non-profit organizations should recruit more pediatricians to provide preventative dental checkups during well-child visits.
  5. Transformation Waiver. The new "Medi-Cal 20-20 Waiver" includes provisions to implement the "Dental Transformation Initiative" (DTI), which aims to improve dental health for Medi-Cal children by focusing on high-value care, improved access, and utilization of performance measures to drive delivery system reform. The DTI provides incentive payments to Medi-Cal dental providers who meet certain requirements and benchmarks. The DTI provides $148 million annually in funding for five years for a maximum of $750 million. More specifically, DTI will include three domains: preventive service, caries risk assessment and management, and continuity of care. Specific incentive payments within each domain will be available to qualified providers, along with messaging and education to providers and beneficiaries about programs and efforts in their local communities.

1. SUPPORT. The LHC states that in its 2016 report, Fixing Denti-Cal, the LHC found the program to be lacking in multiple areas. The LHC made several recommendations aimed at expanding access to Denti-Cal services, with an ultimate goal of 66% of Denti-Cal-eligible children making annual dental visits. Several of those recommendations would require DHCS to take action to improve Denti-Cal from within. This bill would call on DHCS to expedite provider enrollment by creating a dental-specific enrollment form and pursuing alternative automatic enrollment for dentists already established commercially. This bill would also require DHCS to monitor access and utilization and explore additional opportunities to improve Denti-Cal. The LHC concludes that because this bill requires DHCS to improve and expand Denti-Cal provider enrollment, and shares the LHC’s overall goal of expanding access to care, it supports this measure.

The County Health Executives Association of California state that this bill proposes modest changes to the program, including expediting dental provider enrollment into the Medi-Cal program, ensuring screenings are provided for every eligible Medi-Cal beneficiary as part of their initial health assessment, and ensuring beneficiaries are referred to appropriate Medi-Cal dental providers, which could improve the delivery of dental services to those most in need in California.

1. SUPPORT IF AMENDED. The Maternal and Child Health Access strongly supports the provisions of this bill, but urge amendments to clarify the intent that all pregnant women in Medi-Cal benefit from this bill's reforms, add performance measures unique to pregnant and postpartum beneficiaries, include maternal and infant health advocates in the stakeholder group and require DHCS to report access, and quality data for pregnant beneficiaries.

Western Center on Law and Poverty also supports this bill, and urge amendments that add quality performance measures for adults, require the Denti-Cal provider referral list to be updated, and review ways to stream the Treatment Authorization Requests process.

1. RELATED LEGISLATION.
   1. AB 648 (Low) establishes the Virtual Dental Home program to expand the virtual dental home model of community-based delivery of dental care and directs the California Health Facilities Financing Authority to administer the grant program. AB 648 is on the Senate Inactive File.
   2. AB 2108 (Waldron) requires DHCS, on or before January 1, 2018, to submit a report to the Legislature on the cost and feasibility of restoring full adult dental services as a covered benefit under the Medi-Cal Program and sunsets those provisions on January 1, 2019. AB 2108 is pending in the Assembly Health Committee.
2. PREVIOUS LEGISLATION. AB 1467 (Committee on Budget), Chapter 23, Statutes of 2012, allows Sacramento County to establish a stakeholder advisory committee (SC-SAC) to provide input on the delivery of oral health and dental care and required DHCS and the Sacramento County Department of Health and Human Services advisory committee to meet with the SC-SAC. Authorizes the Director of DHCS to establish a beneficiary dental exception process in which Medi-Cal beneficiaries who are mandatorily enrolled in dental health plans in Sacramento County can move to FFS Denti-Cal. Requires DHCS to establish a list of performance measures to ensure that dental health plans meet quality criteria and required DHCS to post on its Website on a quarterly basis, beginning January 1, 2013, the list of performance measures and each plan's performance and made other changes to DMC as specified.
3. COMMITTEE AMENDMENTS.
   1. Disenrollment process clarification. The Committee recommends an amendment clarifying that if 12 months have passed since an enrolled Denti-Cal provider has made a claim for services rendered to a Denti-Cal beneficiary, a notice should be provided to that provider informing them that within 6 months they will be disenrolled from the Denti-Cal program.
   2. Distribution of providers and services. The author wishes to amend the bill to add to the list of performance measures established by DHCS data regarding the number of patients seen by a Dent-Cal provider in one calendar year, and the number of services rendered by that provider.

REGISTERED SUPPORT / OPPOSITION:

Support

California Dental Association

Children Now

California Primary Care Association

Children's Partnership

County Health Executives Association of California

First 5 Association of California

National Association of Social Workers – California Chapter

The Little Hoover Commission

Opposition

None on file.

Analysis Prepared by: Paula Villescaz / HEALTH / (916) 319-2097