California Legislature—2015–16 Regular Session

Assembly Bill No. 2207

Introduced by Assembly Member Wood

February 18, 2016

An act to amend Sections 14132.915 and 14459.6 of, and to add Article 4.10 (commencing with Section 14149.8) to Chapter 7 of Part 3 of Division 9 of, the Welfare and Institutions Code, relating to Medi-Cal.

LEGISLATIVE COUNSEL’S DIGEST

AB 2207, as introduced, Wood. Medi-Cal: dental program.

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 plan’s performance on the department’s 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 plan’s 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.

Vote: majority. Appropriation: no. Fiscal committee: yes. State-mandated local program: no.

The people of the State of California do enact as follows:

SECTION 1.  

Section 14132.915 of the Welfare and Institutions
Code is amended to read:

14132.915.  

(a) (1) The department shall establish a list of
performance measures to ensure the dental fee-for-service program
meets quality and access criteria required by the department. The
performance measures shall be designed to evaluate utilization,
access, availability, and effectiveness of preventive care and
treatment.

(2) Prior to establishing the quality and access criteria described
in paragraph (1), the department shall consult with stakeholders,
including representatives from counties, local dental societies,
nonprofit entities, legal aid entities, and other interested parties.

(3) The performance measures established by the department
to monitor the dental fee-for-service program for children shall
include, but not be limited to, all of the following:

(A) Overall utilization of dental services.

(B) Number of annual dental visits, preventive dental services,
dental treatment services, and examinations and oral health
evaluations.

(C) Number of applications of dental sealants.

(D) Continuity of care and overall utilization over an extended
period of time.

(E) All of the following ratios:

(i) Sealant to restoration.

(ii) Filling to preventive services.

(iii) Treatment to caries prevention.

(4) The performance measures established by the department
to monitor the dental fee-for-service program for adults shall
include, but not be limited to, all of the following:

(A) Number of annual dental visits and preventive dental
services.

(B) Treatment to caries prevention ratio.

(5) The performance measures shall be reported as aggregate
numbers and as percentages, if appropriate, using standards that
are as equivalent to those used by managed care entities as feasible.
Performance measures for the dental fee-for-service program for
children shall be reported by age groupings if appropriate.

(b) The department shall include the initial list of performance
measures in any dental contract entered into between the
department and a fee-for-service contractor on or after enactment
of this section.

(c) To ensure that the dental health needs of Medi-Cal
beneficiaries are met, the department shall, when evaluating
performance measures for retention on, addition to, or deletion
from, the list of performance measures, consider all of the
following criteria:

(1) Annual and multiyear Medi-Cal dental fee-for-service
trended data.

(2) Other state and national dental program performance and
quality measures.

(3) Other state and national performance ratings.

(d)  begin delete Commencing end delete begin insert On end insert October 1, 2014, for the 2013 calendar
year, and begin delete annually end delete on or before begin delete October 1 for each preceding
calendar year thereafter, end delete begin insert October 1, 2016, for the 2015 calendar
year, end insert the list of performance measures established by the
department along with the data of the dental fee-for-service
program performance shall be posted on the department’s Internet
Web site.

begin insert

(e) Commencing January 31, 2017, for the 2015-16 fiscal year,
and annually on or before January 31 for each preceding fiscal
year thereafter, the list of performance measures established by
the department along with the data of the dental fee-for-service
program shall be posted on the department’s Internet Web site.

end insert begin insert

(f) Commencing April 30, 2017, for the July 2016 to September
2016, inclusive, fiscal quarter, and quarterly thereafter on or
before April 30, July 31, October 31, and January 31 for the fiscal
quarter ending seven months prior, the data of the dental
fee-for-service program performance shall be posted on the
department’s Internet Web site.

end insert begin delete

(e)

end delete

begin insert (g) end insert  The department may amend or remove performance
measures and establish additional performance measures in
accordance with all of the following:

(1) The department shall consider performance measures
established by other states, the federal government, and national
organizations developing dental program performance and quality
measures.

(2) The department shall notify a fee-for-service contractor, at
least 30 days prior to the implementation date, of any updates or
changes to performance measures. The department shall also post
these updates or changes on its Internet Web site at least 30 days
prior to implementation in order to maintain transparency to the
public.

(3) In establishing the performance measures, the department
shall consult with stakeholders, including representatives from
counties, local dental societies, nonprofit entities, legal aid entities,
and other interested parties.

begin delete

(f)

end delete

begin insert (h) end insert  The department shall annually prepare a summary report of
the nature and types of complaints and grievances regarding access
to, and quality of, dental services, including the outcome.
Commencing begin delete no sooner than October 1, 2015, end delete begin insert January 31, 2017, end insert
for the prior begin delete calendar end delete begin insert fiscal end insert year, and annually thereafter, for each
preceding begin delete calendar end delete begin insert fiscal end insert year, this report shall be posted on the
department’s Internet Web site.

begin insert

(i) The department shall ensure, to the greatest degree possible,
that the categories of data and performance measures selected
under this section are consistent with the categories of data and
performance measures selected under Section 14459.6.

end insert

SEC. 2.  

Article 4.10 (commencing with Section 14149.8) is
added to Chapter 7 of Part 3 of Division 9 of the Welfare and
Institutions Code, to read:

 

Article 4.10.  Medi-Cal Dental Program

 

14149.8.  

(a) The department shall expedite the enrollment of
Medi-Cal dental providers by streamlining the Medi-Cal provider
enrollment process. The department shall pursue all of the
following activities, to the extent permitted by federal law:

(1) Create a dental-specific enrollment form.

(2) Pursue an alternative automatic enrollment process for a
provider already commercially credentialed by either a dental
fee-for-service 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.

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

(b) The department shall maintain the provider network by
disenrolling a billing and rendering provider who has not
participated in the dental program, as determined by the
department, for more than a continuous one-year period. In order
to improve the quality of the dental provider network, the
department also shall exercise additional measures as appropriate
and permitted by law, including, but not limited to, temporary
suspensions.

(c) (1) The department shall monitor access and utilization of
Medi-Cal dental services in the fee-for-service and managed care
delivery systems to assess opportunities to improve access and
utilization.

(2) The department shall assess opportunities to develop and
implement innovative payment reform proposals within the
Medi-Cal dental programs.

(d) The department shall explore additional opportunities to
improve the Medi-Cal Dental Program, in consultation with
stakeholders and as deemed appropriate by the department and to
the extent permitted by federal law, 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.

(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.

(e) Prior to implementing an action pursuant to subdivision (g),
the department shall post the proposed action on its Internet Web
site at least 30 days before implementation.

(f) The department shall work with dental managed care plans
that contract with the department for the purposes of implementing
the Medi-Cal Dental Program, which includes, but is not limited
to, contracts authorized pursuant to Sections 14104.3, Sections
14087.46, 14089, and 14104.3, and 14089, to provide beneficiaries
with access to plan liaisons to assist in the coordination of care for
enrolled members.

(g) A Medi-Cal managed care health plan shall 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.

(3) Identify plan liaisons available to dental managed care
contractors and dental fee-for-service contractors to assist in
coordination of care.

(h) (1) To increase the efficiency and timeliness of changes,
any contract amendment, modification, or change order to any
contract entered into by the department for the purposes of
implementing the state Medi-Cal Dental Program shall be exempt,
except as provided in paragraph (2), from Part 2 (commencing
with Section 10100) of Division 2 of the Public Contract Code, as
well as Sections 11545 and 11546 of the Government Code, in
addition to any policies, procedures, or regulations authorized by
those provisions.

(2) Paragraph (1) shall not exempt the department from
establishing a competitive bid process for awarding new contracts
pursuant to Section 14104.3, as well as for awarding new dental
contracts pursuant to Sections 14087.46 and 14089.

(i) Prior to implementing any change pursuant to this section,
the department shall consult with, and provide notification to,
stakeholders, including representatives from counties, local dental
societies, nonprofit entities, legal aid entities, and other interested
parties.

(j) Notwithstanding Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code,
the department, without taking any further regulatory action, shall
implement, interpret, or make specific policies and procedures
pertaining to the dental fee-for-service program and dental managed
care plans, as well as applicable federal waivers and state plan
amendments, including the provisions set forth in this section, by
means of all-county letters, plan letters, plan or provider bulletins,
or similar instructions until regulations are adopted. Thereafter,
the department shall adopt regulations in accordance with the
requirements of Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code. Beginning
six months after the effective date of this section, and
notwithstanding Section 10231.5 of the Government Code, the
department shall provide a status report to the Legislature on a
semiannual basis until regulations have been adopted.

(k) This section shall be implemented only to the extent that all
of the following occur:

(1) The department obtains any federal approvals necessary to
implement this section.

(2) The department obtains federal matching funds to the extent
permitted by federal law.

(3) The department receives an appropriation in the annual
Budget Act each fiscal year for the specific purpose of
implementing this section.

SEC. 3.  

Section 14459.6 of the Welfare and Institutions Code
is amended to read:

14459.6.  

(a) The department shall establish a list of
performance measures to ensure dental health plans meet quality
criteria required by the department. The list shall specify the
benchmarks used by the department to determine whether and the
extent to which a dental health plan meets each performance
measure. Commencing January 1, 2013, and quarterly thereafter,
the list of performance measures established by the department
along with each plan’s performance shall be posted on the
department’s Internet Web site. The Department of Managed
Health Care and the advisory committee established pursuant to
Section 14089.08 shall have access to all performance measures
and benchmarks used by the department as described in this
section.

begin insert

(1) Commencing April 30, 2017, the quarterly reporting required
by this subdivision shall be posted in the following manner:

end insert begin insert

(A) On or before April 30, 2017, the reporting shall be posted
for the July 2016 to September 2016 inclusive, fiscal quarter.

end insert begin insert

(B) After April 30, 2017, the reporting shall be posted on a
quarterly basis on or before April 30, July 31, October 31, and
January 31 for the fiscal quarter ending seven months prior.

end insert begin delete

(1)

end delete

begin insert (2) end insert  The performance measures established by the department
shall include, but not be limited to, all of the following: 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,
sealant to restoration ratio, filling to preventive services ratio,
treatment to caries prevention ratio, use of dental sealants, use of
diagnostic services, and survey of member satisfaction with plans
and providers.

begin delete

(2)

end delete

begin insert (3) end insert  The survey of member satisfaction with plans and providers
shall be the same dental version of the Consumer Assessment of
Healthcare Providers and Systems (CAHPS) survey as used by
the Healthy Families Program.

begin delete

(3)

end delete

begin insert (4) end insert  The department shall notify dental health plans at least 30
days prior to the implementation date of these performance
measures.

begin delete

(4)

end delete

begin insert (5) end insert  The department shall include the initial list of performance
measures and benchmarks in any dental health contracts entered
into between the department and a dental health plan pursuant to
Section 14204.

begin delete

(5)

end delete

begin insert (6) end insert  The department shall update performance measures and
benchmarks and establish additional performance measures and
benchmarks in accordance with all of the following:

(A) The department shall consider performance measures and
benchmarks established by other states, the federal government,
and national organizations developing dental program performance
and quality measures.

(B) The department shall notify dental health plans at least 30
days prior to the implementation date of updates or changes to
performance measures and benchmarks. The department shall also
post these updates or changes on its Internet Web site at least 30
days prior to implementation in order to provide transparency to
the public.

(C) To ensure that the dental health needs of Medi-Cal
beneficiaries are met, the department shall, when evaluating
performance measures and benchmarks for retention on, addition
to, or deletion from the list, consider all of the following criteria:

(i) Monthly, quarterly, annual, and multiyear Medi-Cal dental
managed care trended data.

(ii) County and statewide Medi-Cal dental fee-for-service
performance and quality ratings.

(iii) Other state and national dental program performance and
quality measures.

(iv) Other state and national performance ratings.

(b) In establishing and updating the performance measures and
benchmarks, the department shall consult the advisory committee
established pursuant to Section 14089.08, as 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.

(c) In evaluating a dental health plan’s ability to meet the criteria
established through the performance measures and benchmarks,
the department shall select specific performance measures from
those established by the department in subdivision (a) 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. These
incentives and disincentives shall be included in the dental health
plan contracts.

(d) (1) The department shall designate an external quality
review organization (EQRO) that shall conduct external quality
reviews for any dental health plan contracting with the department
pursuant to Section 14204.

(2) As determined by the department, but at least annually,
dental health plans shall arrange for an external quality of care
review with the EQRO designated by the department that evaluates
the dental health plan’s performance in meeting the performance
measures established in this section. Dental health plans shall
cooperate with and assist the EQRO in this review. The Department
of Managed Health Care shall have direct access to all external
quality of care review information upon request to the department.

(3) An external quality of care review shall include, but not be
limited to, all of the following: performance on the selected
performance measures and benchmarks established and updated
by the department, the CAHPS member or consumer satisfaction
survey referenced in paragraph (2) of subdivision (a), reporting
systems, and methodologies for calculating performance measures.
An external quality of care review that includes all of the above
components shall be paid for by the dental health plan and posted
online annually, or at any other frequency specified by the
department, on the department’s Internet Web site.

(e) All marketing methods and activities to be used by dental
plans shall comply with subdivision (b) of Section 10850, Sections
14407.1, 14408, 14409, 14410, and 14411, and Title 22 of the
California Code of Regulations, including Sections 53880 and
53881. Each dental plan shall submit its marketing plan to the
department for review and approval.

(f) Each dental plan shall submit its member services procedures,
beneficiary informational materials, and any updates to those
procedures or materials to the department for review and approval.
The department shall 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.

(g) Each dental plan shall submit its provider compensation
agreements to the department for review and approval.

(h) The department shall post to its Internet Web site a copy of
all final reports completed by the Department of Managed Health
Care regarding dental managed care plans.

begin insert

(i) The department shall ensure, to the greatest degree possible,
that the categories of data and performance measures selected
under this section are consistent with the categories of data and
performance measures selected under Section 14132.915.

end insert