BILL ANALYSIS Ó
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: AB 1051
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|AUTHOR: |Maienschein |
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|VERSION: |May 3, 2016 |
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|HEARING DATE: |June 29, 2016 | | |
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|CONSULTANT: |Scott Bain |
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SUBJECT : Denti-Cal program
SUMMARY : Appropriates $200 million dollars from the General Fund to the
Department of Health Care Services (DHCS) for the Denti-Cal
program. Requires DHCS to allocate the funds appropriated 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.
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)Reduces specified Medi-Cal provider rates (including dental
services), effective June 1, 2011, by 10% for dates of
services on and after June 1, 2011, subject to federal
approval, federal financial participation (FFP), and the
reduction meeting federal Medicaid requirements. If the
director of DHCS determines that the payments do not comply
with federal Medicaid requirements or that FFP is not
available with respect to any payment that is reduced, the
director retains the discretion to not implement the
particular payment reduction and to adjust the payment as
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necessary to comply with federal Medicaid requirements. 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.
3)Requires the DHCS director to annually review the
reimbursement levels for physician and dental services under
Medi-Cal, and to revise periodically the rates of
reimbursement to physicians and dentists to ensure the
reasonable access of Medi-Cal beneficiaries to physician and
dental services.
This bill:
1)Appropriates $200 million dollars from the General Fund (GF)
to DHCS for the Denti-Cal program.
2)Requires DHCS to allocate the funds appropriated, as
appropriate, to accomplish both of the following:
a) To increase reimbursement rates for the 15 most
common prevention, treatment, and oral evaluation
services to the Medicaid national average; and,
b) 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 the program.
3)States legislative intent to attract and retain more
providers, with an emphasis on underserved areas, and to
increase utilization of the program.
4)Requires any funds remaining after the allocation to be
allocated to other uses that further the legislative intent,
including, but not limited to, increasing additional
reimbursement rates to the national average.
5)Makes the following legislative findings and declarations:
a) Denti-Cal is charged with providing an adequate
level of dental coverage to 13 million low-income
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Californians, including five million children;
b) Dental care, particularly preventative care, can
have significant long-term impacts, including that tooth
decay and disease are associated with pregnancy risks,
diabetes, and respiratory and heart disease, and a lack
of access to dental care among children can result in
missed school days, and ultimately poorer academic
performance;
c) Denti-Cal is a failure as just 37.8% of California's
five million Denti-Cal-eligible children saw a dentist in
the 2014;
d) The Little Hoover Commission State Auditor both note
these low utilization rates, which stem from a lack of
providers and an uneven distribution of those providers
that do participate in the Denti-Cal program, and that
five counties have no providers, and 14 counties only
have providers that are not accepting new patients; and,
e) The lack of providers is partly a result of low
reimbursement rates, which are typically one-third to
one-half of the national average for common procedures.
FISCAL
EFFECT : This bill has not been analyzed by a fiscal committee.
PRIOR
VOTES :
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|Assembly Floor: |Not relevant |
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|Assembly Appropriations Committee: |Not relevant |
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|Assembly Public Safety Committee: |Not relevant |
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COMMENTS :
1)Author's statement. According to the author, Denti-Cal
provides dental coverage for more than 14 million
Californians, including 5 million children, but has been
chronically underfunded. Recent reports by the State Auditor
and Little Hoover Commission found that less than 38% of
Denti-Cal-eligible children received dental care in 2014.
Denti-Cal consistently falls short in caring for the one-third
of our state's residents and half of our children that are
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covered by it.
The system has been described as broken, dysfunctional and an
outright mess. Not only are costs higher than average in
California, but low reimbursement rates make it difficult for
children to find a dentist to provide routine care.
Reimbursement rates currently hovers around 35% of the
national average.
Tooth decay and disease are associated with pregnancy risks,
diabetes, and respiratory and heart diseases. The inability to
obtain proper dental care can have significant long-term
impacts, which contribute to multi-generational poverty. Our
state health and social safety net programs should provide
hope and opportunity for low-income Californians, not make
life harder.
2)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:
a) 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,
b) 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) for every
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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.
1)Denti-Cal rates. On July 1, 2015, 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.
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2)Dental Transformation Initiative (DTI) ofMedi-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:
a) Domain 1: Increase Preventive Services Utilization for
Children;
b) Domain 2: Caries Risk Assessment and Disease Management;
c) Domain 3: Increase Continuity of Care; and,
d) Domain 4: Local Dental Pilot Programs.
1)Related legislation. SB 1098 (Cannella), would establish 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.
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 off the
Assembly Floor on June 23, 2016 and AB 1568 passed off the
Senate Floor on June 23, 2016.
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AB 2077 (Wood) would require DHCS to expedite the 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. AB 2077 is
currently in the Senate Appropriations Committee.
2)Prior legislation.
a) 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.
b) 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.
c) 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 California Dental Association (CDA) writes in
support that numerous reports over the past several years have
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consistently highlighted the insufficiencies and dysfunction
of the state's dental program, including reimbursement rates
among the nation's lowest, an abundance of restrictive rules,
and reliance on outdated paper-based administrative processes.
A 2014 report from the State Auditor found that more than half
of the children enrolled in Denti-Cal did not receive any
dental care in the previous year, and that there is a lack of
providers in a number of California counties, including five
counties with at least 2,000 children that may not have any
active dental providers. The most recent report, released by
the Little Hoover Commission in March, found that the program
consistently falls short in its purpose to provide quality
dental care for 13 million low-income Californians, including
over 5 million children.
CDA writes, that while is appreciates the positive steps
currently underway to address the program's deficiencies, it
is clear that additional funding for provider rates must be a
part of the solution. The increased funding in AB 1051 would
go toward raising provider rates to the national average for
the most common services, as well as increasing the emphasis
on preventive care, case management services and bringing
providers into the program. Additional funding to increase
provider participation in the program will be essential in
addressing Denti-Cal's current access crisis. The inability to
find and receive dental care creates devastating personal
consequences for both children and adults, including pain and
infection, poor diet and nutrition due to impaired eating,
tooth loss, missed school and workdays, and diminished
employability.
2)Policy issues.
a) Appropriation amount and national Medicaid average. This
bill appropriates $200 million from the GF to increase
Denti-Cal reimbursement rates for the 15 most common
prevention, treatment, and oral evaluation services to the
Medicaid national average. It is unclear what the national
average is for dental services, or if the dollar amount of
the appropriation is sufficient or in excess of the amount
needed to increase rates to the national average. DHCS's
June 2015 rate review has data on at least four comparable
states (New York, Illinois, Connecticut, and Texas). The
author indicates $200 million figure is an estimate based
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on a 2015 proposal from CDA, which called for increased
rates for the top 10 procedures, and as the bill
progresses, the author hopes to work with DHCS on a more
refined figure. In addition, it is unclear whether the
Medicaid national average is an appropriate benchmark as a
dental provider would likely decide whether or not to
accept Denti-Cal patients on the basis of commercial and
private pay rates in his or her community, as opposed to
rates paid by other states' Medicaid programs.
b) Preventive care and case management. This bill requires
DHCS to use the $200 million (in addition to increasing
Denti-Cal reimbursement rates for the 15 most common
prevention, treatment, and oral evaluation services to the
Medicaid national average) to increase funding for
preventative care and case management services, as
appropriate. DHCS indicates there are no definitions of
"preventative care" or "case management" in the Provider
Handbook for the Denti-Cal program, but there are
identified preventive services by CDT code with associated
rates that can be located in the Provider Handbook. DHCS
indicates and that case management has neither a definition
nor an associated CDT code in the Denti-Cal program.
SUPPORT AND OPPOSITION :
Support: California Academy of General Dentistry
California Academy of PAs
California Dental Association
First 5 California
Little Hoover Commission
United Ways of California
Western Center Law & Poverty
Western Dental and Orthodontics
Oppose: None received
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