BILL NUMBER: SB 1403	CHAPTERED  07/07/06

	CHAPTER  61
	FILED WITH SECRETARY OF STATE  JULY 7, 2006
	APPROVED BY GOVERNOR  JULY 7, 2006
	PASSED THE ASSEMBLY  JUNE 27, 2006
	PASSED THE SENATE  MAY 18, 2006
	AMENDED IN SENATE  APRIL 24, 2006
	AMENDED IN SENATE  APRIL 5, 2006

INTRODUCED BY   Senator Scott
   (Coauthors: Senators Aanestad and Bowen)
   (Coauthors: Assembly Members Emmerson, Oropeza, and Pavley)

                        FEBRUARY 22, 2006

   An act to amend Section 14132.88 of the Welfare and Institutions
Code, relating to Medi-Cal.


	LEGISLATIVE COUNSEL'S DIGEST


   SB 1403, Scott  Medi-Cal: dental restoration documentation
requirements.
   Existing law provides for the Medi-Cal program, which is
administered by the State Department of Health Services and under
which qualified low-income persons and other eligible persons are
provided health care services.
   Under existing law, specified dental services are included as
covered benefits under the Medi-Cal program, subject to utilization
controls.
   Existing law requires the department to require, under specified
circumstances, pretreatment radiograph documentation on posttreatment
claims for dental restorations.
   This bill would specify that, for any beneficiary who is under 4
years of age, or who, regardless of age, has a developmental
disability, as defined, radiographs or photographs that indicate
decay on any tooth surface shall be considered sufficient
documentation to establish the medical necessity for treatment
provided.
   Existing law authorizes the department to implement the
requirements for that documentation by means of a provider bulletin
or similar instruction, without taking regulatory action.
   This bill would, instead, require the department to implement
those requirements by that means.


THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:


  SECTION 1.  Section 14132.88 of the Welfare and Institutions Code
is amended to read:
   14132.88.  (a) Notwithstanding subdivision (h) of Section 14132
and to the extent funds are made available in the annual Budget Act
for this purpose, the following are covered benefits for
beneficiaries 21 years of age or older under this chapter:
   (1) One dental prophylaxis cleaning per year.
   (2) One initial dental examination by a dentist.
   (b) The following are covered benefits for beneficiaries under 21
years of age under this chapter:
   (1) Two dental prophylaxis cleanings per year.
   (2) Two periodic dental examinations per year.
   (c) For persons 21 years of age or older, laboratory-processed
crowns on posterior teeth are not a covered benefit except when a
posterior tooth is necessary as an abutment for any fixed or
removable prosthesis.
   (d) Any prefabricated crown made from ADA-approved materials may
be used on posterior teeth and may be reimbursed as a stainless steel
crown.
   (e) The department shall reduce the rate of subgingival curettage
and root planing by 41 percent for all beneficiaries except those
residing in a skilled nursing facility or an intermediate care
facility for the developmentally disabled. Notwithstanding Section
14105 and Chapter 3.5 (commencing with Section 11340) of Part 1 of
Division 3 of Title 2 of the Government Code, the department may
implement this subdivision by means of a provider bulletin or similar
instruction, without taking regulatory action.
   (f) (1) Except as provided in paragraph (2), the department shall
require pretreatment radiograph documentation on posttreatment claims
to establish the medical necessity for dental restorations. The
pretreatment documentation required under this subdivision is
intended to reduce fraudulent claims for unnecessary dental fillings.
  In order to avoid any undue barriers to accessing dental care, the
department shall stipulate that the pretreatment radiograph
documentation for posttreatment claims will be required only when
there are four or more dental fillings being completed in any
12-month period.
   (2) For any beneficiary who is under four years of age, or who,
regardless of age, has a developmental disability, as defined in
subdivision (a) of Section 4512, radiographs or photographs that
indicate decay on any tooth surface shall be considered sufficient
documentation to establish the medical necessity for treatment
provided.
   (3) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department shall implement this subdivision by means of a provider
bulletin or similar instruction, without taking regulatory action.