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 14132.915 of the Welfare and Institutions
2Code is amended to read:
(a) (1) The department shall establish a list of
4performance measures to ensure the dental fee-for-service program
5meets quality and access criteria required by the department. The
6performance measures shall be designed to evaluate utilization,
P3 1access, availability, and effectiveness of preventive care and
3(2) Prior to establishing the quality and access criteria described
4in paragraph (1), the department shall consult with stakeholders,
5including representatives from counties, local dental societies,
6nonprofit entities, legal aid entities, and other interested parties.
7(3) The performance measures established by the department
8to monitor the dental fee-for-service program for children shall
9include, but not be limited to, all of the following:
10(A) Overall utilization of dental services.
11(B) Number of annual dental visits, preventive dental services,
12dental treatment services, and examinations and oral health
14(C) Number of applications of dental sealants.
15(D) Continuity of care and overall utilization over an extended
16period of time.
17(E) All of the following ratios:
18(i) Sealant to restoration.
19(ii) Filling to preventive services.
20(iii) Treatment to caries prevention.
21(4) The performance measures established by the department
22to monitor the dental fee-for-service program for adults shall
23include, but not be limited to, all of the following:
24(A) Number of annual dental visits and preventive dental
26(B) Treatment to caries prevention ratio.
27(5) The performance measures shall be reported as aggregate
28numbers and as percentages, if appropriate, using standards that
29are as equivalent to those used by managed care entities as feasible.
30Performance measures for the dental fee-for-service program for
31children shall be reported by age groupings if appropriate.
32(b) The department shall include the initial list of performance
33 measures in any dental contract entered into between the
34department and a fee-for-service contractor on or after enactment
35of this section.
36(c) To ensure that the dental health needs of Medi-Cal
37beneficiaries are met, the department shall, when evaluating
38performance measures for retention on, addition to, or deletion
39from, the list of performance measures, consider all of the
P4 1(1) Annual and multiyear Medi-Cal dental fee-for-service
3(2) Other state and national dental program performance and
5(3) Other state and national performance ratings.
begin deleteCommencing end deleteOctober 1, 2014, for the 2013 calendar
begin delete annuallyend delete on or before begin delete October 1 for each preceding the list of performance measures established by the
8calendar year thereafter,end delete
10department along with the data of the dental fee-for-service
11program performance shall be posted on the department’s Internet
25 The department may amend or remove performance
26measures and establish additional performance measures in
27accordance with all of the following:
28(1) The department shall consider performance measures
29established by other states, the federal government, and national
30organizations developing dental program performance and quality
32(2) The department shall notify a fee-for-service contractor, at
33least 30 days prior to the implementation date, of any updates or
34changes to performance measures. The department shall also post
35these updates or changes on its Internet Web site at least 30 days
36prior to implementation in order to maintain transparency to the
38(3) In establishing the performance measures, the department
39shall consult with stakeholders, including representatives from
P5 1counties, local dental societies, nonprofit entities, legal aid entities,
2and other interested parties.
4 The department shall annually prepare a summary report of
5the nature and types of complaints and grievances regarding access
6to, and quality of, dental services, including the outcome.
begin delete no sooner than October 1, 2015,end delete
8 for the prior
begin delete calendarend delete year, and annually thereafter, for each
begin delete calendarend delete year, this report shall be posted on the
10department’s Internet Web site.
Article 4.10 (commencing with Section 14149.8) is
16added to Chapter 7 of Part 3 of Division 9 of the Welfare and
17Institutions Code, to read:
(a) The department shall expedite the enrollment of
22Medi-Cal dental providers by streamlining the Medi-Cal provider
23enrollment process. The department shall pursue all of the
24following activities, to the extent permitted by federal law:
25(1) Create a dental-specific enrollment form.
26(2) Pursue an alternative automatic enrollment process for a
27provider already commercially credentialed by either a dental
28fee-for-service contractor or an administrative services contractor
29for the purpose of providing services as a commercial provider.
30(3) Discontinue requiring providers to resubmit an enrollment
31application that has been deemed incomplete if the missing
32information is available elsewhere within the application packet.
33(4) To the extent that the department expedites the enrollment
34of Medi-Cal dental providers by streamlining the Medi-Cal
35provider enrollment process, the department shall publish the
36criteria for those processes in applicable provider bulletins and
38(b) The department shall maintain the provider network by
39disenrolling a billing and rendering provider who has not
40participated in the dental program, as determined by the
P6 1department, for more than a continuous one-year period. In order
2to improve the quality of the dental provider network, the
3department also shall exercise additional measures as appropriate
4and permitted by law, including, but not limited to, temporary
6(c) (1) The department shall monitor access and utilization of
7Medi-Cal dental services in the fee-for-service and managed care
8delivery systems to assess opportunities to improve access and
10(2) The department shall assess opportunities to develop and
11implement innovative payment reform proposals within the
12Medi-Cal dental programs.
13(d) The department shall explore additional opportunities to
14improve the Medi-Cal Dental Program, in consultation with
15stakeholders and as deemed appropriate by the department and to
16the extent permitted by federal law, including, but not limited to,
18(1) Aligning the provision of dental anesthesia services with
19that of medical anesthesia services, including the ability to bill for
20applicable facility fees and ancillary services.
21(2) Adjusting other utilization controls for specialty services,
22as appropriate, to promote access to care while still protecting
24(3) Expanding the scope of beneficiary outreach activities
25required by an entity that is contracted with the department to more
26broadly address underutilization throughout the state.
27(e) Prior to implementing an action pursuant to subdivision (g),
28the department shall post the proposed action on its Internet Web
29site at least 30 days before implementation.
30(f) The department shall work with dental managed care plans
31that contract with the department for the purposes of implementing
32the Medi-Cal Dental Program, which includes, but is not limited
33to, contracts authorized pursuant to Sections 14104.3, Sections
34 14087.46, 14089, and 14104.3, and 14089, to provide beneficiaries
35with access to plan liaisons to assist in the coordination of care for
37(g) A Medi-Cal managed care health plan shall do all of the
39(1) Provide dental screenings for every eligible beneficiary as
40a part of the beneficiary’s initial health assessment.
P7 1(2) Ensure that an eligible beneficiary is referred to an
2appropriate Medi-Cal dental provider.
3(3) Identify plan liaisons available to dental managed care
4contractors and dental fee-for-service contractors to assist in
5coordination of care.
6(h) (1) To increase the efficiency and timeliness of changes,
7any contract amendment, modification, or change order to any
8contract entered into by the department for the purposes of
9implementing the state Medi-Cal Dental Program shall be exempt,
10except as provided in paragraph (2), from Part 2 (commencing
11with Section 10100) of Division 2 of the Public Contract Code, as
12well as Sections 11545 and 11546 of the Government Code, in
13addition to any policies, procedures, or regulations authorized by
15(2) Paragraph (1) shall not exempt the department from
16establishing a competitive bid process for awarding new contracts
17pursuant to Section 14104.3, as well as for awarding new dental
18contracts pursuant to Sections 14087.46 and 14089.
19(i) Prior to implementing any change pursuant to this section,
20the department shall consult with, and provide notification to,
21stakeholders, including representatives from counties, local dental
22societies, nonprofit entities, legal aid entities, and other interested
24(j) Notwithstanding Chapter 3.5 (commencing with Section
2511340) of Part 1 of Division 3 of Title 2 of the Government Code,
26the department, without taking any further regulatory action, shall
27implement, interpret, or make specific policies and procedures
28pertaining to the dental fee-for-service program and dental managed
29care plans, as well as applicable federal waivers and state plan
30amendments, including the provisions set forth in this section, by
31means of all-county letters, plan letters, plan or provider bulletins,
32or similar instructions until regulations are adopted. Thereafter,
33the department shall adopt regulations in accordance with the
34requirements of Chapter 3.5 (commencing with Section 11340) of
35Part 1 of Division 3 of Title 2 of the Government Code. Beginning
36six months after the effective date of this section, and
37notwithstanding Section 10231.5 of the Government Code, the
38department shall provide a status report to the Legislature on a
39semiannual basis until regulations have been adopted.
P8 1(k) This section shall be implemented only to the extent that all
2of the following occur:
3(1) The department obtains any federal approvals necessary to
4implement this section.
5(2) The department obtains federal matching funds to the extent
6permitted by federal law.
7(3) The department receives an appropriation in the annual
8Budget Act each fiscal year for the specific purpose of
9implementing this section.
Section 14459.6 of the Welfare and Institutions Code
11 is amended to read:
(a) The department shall establish a list of
13performance measures to ensure dental health plans meet quality
14criteria required by the department. The list shall specify the
15benchmarks used by the department to determine whether and the
16extent to which a dental health plan meets each performance
17measure. Commencing January 1, 2013, and quarterly thereafter,
18the list of performance measures established by the department
19along with each plan’s performance shall be posted on the
20department’s Internet Web site. The Department of Managed
21Health Care and the advisory committee established pursuant to
22Section 14089.08 shall have access to all performance measures
23and benchmarks used by the department as described in this
33 The performance measures
established by the department
34shall include, but not be limited to, all of the following: provider
35network adequacy, overall utilization of dental services, annual
36dental visits, use of preventive dental services, use of dental
37treatment services, use of examinations and oral health evaluations,
38sealant to restoration ratio, filling to preventive services ratio,
39treatment to caries prevention ratio, use of dental sealants, use of
P9 1diagnostic services, and survey of member satisfaction with plans
4 The survey of member satisfaction with plans and providers
5shall be the same dental version of the Consumer Assessment of
6Healthcare Providers and Systems (CAHPS) survey as used by
7the Healthy Families Program.
9 The department shall notify dental health plans at least 30
10days prior to the implementation date of these performance
13 The department shall include the initial list of performance
14measures and benchmarks in any dental health contracts entered
15into between the department and a dental health plan pursuant to
18 The department shall update performance measures and
19benchmarks and establish additional performance measures and
20benchmarks in accordance with all of the following:
21(A) The department shall consider performance measures and
22benchmarks established by other states, the federal government,
23and national organizations developing dental program performance
24and quality measures.
25(B) The department shall notify dental health plans at least 30
26days prior to the implementation date of updates or changes to
27performance measures and benchmarks. The department shall also
28post these updates or changes on its Internet Web site at least 30
29days prior to implementation in order to provide transparency to
31(C) To ensure that the dental health needs of Medi-Cal
32beneficiaries are met, the department shall, when evaluating
33performance measures and benchmarks for retention on, addition
34to, or deletion from the list, consider all of the following criteria:
35(i) Monthly, quarterly, annual, and multiyear Medi-Cal dental
36managed care trended data.
37(ii) County and statewide Medi-Cal dental fee-for-service
38performance and quality ratings.
39(iii) Other state and national dental program performance and
P10 1(iv) Other state and national performance ratings.
2(b) In establishing and updating the performance measures and
3benchmarks, the department shall consult the advisory committee
4established pursuant to Section 14089.08, as well as dental health
5plan representatives and other stakeholders, including
6representatives from counties, local dental societies, nonprofit
7entities, legal aid entities, and other interested parties.
8(c) In evaluating a dental health plan’s ability to meet the criteria
9established through the performance measures and benchmarks,
10the department shall select specific performance measures from
11those established by the department in subdivision (a) as the basis
12for establishing financial or other incentives or disincentives,
13including, but not limited to, bonuses, payment withholds, and
14adjustments to beneficiary assignment to plan algorithms. These
15incentives and disincentives shall be included in the dental health
17(d) (1) The department shall designate an external quality
18review organization (EQRO) that shall conduct external quality
19reviews for any dental health plan contracting with the department
20pursuant to Section 14204.
21(2) As determined by the department, but at least annually,
22dental health plans shall arrange for an external quality of care
23review with the EQRO designated by the department that evaluates
24the dental health plan’s performance in meeting the performance
25measures established in this section. Dental health plans shall
26cooperate with and assist the EQRO in this review. The Department
27of Managed Health Care shall have direct access to all external
28quality of care review information upon request to the department.
29(3) An external quality of care review shall include, but not be
30limited to, all of the following: performance on the selected
31performance measures and benchmarks established and updated
32by the department, the CAHPS member or consumer satisfaction
33survey referenced in paragraph (2) of subdivision (a), reporting
34systems, and methodologies for calculating performance measures.
35An external quality of care review that includes all of the above
36components shall be paid for by the dental health plan and posted
37online annually, or at any other frequency specified by the
38department, on the department’s Internet Web site.
39(e) All marketing methods and activities to be used by dental
40plans shall comply with subdivision (b) of Section 10850, Sections
P11 114407.1, 14408, 14409, 14410, and 14411, and Title 22 of the
2California Code of Regulations, including Sections 53880 and
353881. Each dental plan shall submit its marketing plan to the
4department for review and approval.
5(f) Each dental plan shall submit its member services procedures,
6beneficiary informational materials, and any updates to those
7procedures or materials to the department for review and approval.
8The department shall ensure that member services procedures and
9beneficiary informational materials are clear and provide timely
10and fair processes for accepting and acting upon complaints,
11grievances, and disenrollment requests, including procedures for
12appealing decisions regarding coverage or benefits.
13(g) Each dental plan shall submit its provider compensation
14agreements to the department for review and approval.
15(h) The department shall post to its Internet Web site a copy of
16all final reports completed by the Department of Managed Health
17Care regarding dental managed care plans.