Amended in Assembly April 26, 2016

California Legislature—2015–16 Regular Session

Assembly BillNo. 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 amended, 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.

Thisbegin delete bill,end deletebegin insert 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,end insert as of October 31, 2016,begin delete wouldend delete 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:

P2    1

SECTION 1.  

Section 14132.915 of the Welfare and Institutions
2Code
is amended to read:

P3    1

14132.915.  

(a) (1) The department shall establish a list of
2performance measures to ensure the dental fee-for-service program
3meets quality and access criteria required by the department. The
4performance measures shall be designed to evaluate utilization,
5access, availability, and effectiveness of preventive care and
6treatment.

7(2) Prior to establishing the quality and access criteria described
8in paragraph (1), the department shall consult with stakeholders,
9including representatives from counties, local dental societies,
10nonprofit entities, legal aid entities, and other interested parties.

11(3) The performance measures established by the department
12to monitor the dental fee-for-service program for children shall
13include, but not be limited to, all of the following:

14(A) Overall utilization of dental services.

15(B) Number of annual dental visits, begin insertthe total number of patients
16seen, on a per-provider basis, and the total number of end insert
preventive
17dental services, dental treatment services, and examinations and
18oral healthbegin delete evaluations.end deletebegin insert evaluations rendered by each provider
19during each calendar year.end insert

20(C) Number of applications of dental sealants.

21(D) Continuity of care and overall utilization over an extended
22period of time.

23(E) All of the following ratios:

24(i) Sealant to restoration.

25(ii) Filling to preventive services.

26(iii) Treatment to caries prevention.

27(4) The performance measures established by the department
28to monitor the dental fee-for-service program for adults shall
29include, but not be limited to, all of the following:

30(A) Number of annual dental visits and preventive dental
31
begin delete services.end deletebegin insert services, the total number of patients seen on a
32per-provider basis, and the total number of dental services
33rendered by each provider during each calendar year.end insert

34(B) Treatment to caries prevention ratio.

35(5) The performance measures shall be reported as aggregate
36numbers and as percentages, if appropriate, using standards that
37are as equivalent to those used by managed care entities as feasible.
38Performance measures for the dental fee-for-service program for
39children shall be reported by age groupings if appropriate.

P4    1(b) The department shall include the initial list of performance
2 measures in any dental contract entered into between the
3department and a fee-for-service contractor on or after enactment
4of this section.

5(c) To ensure that the dental health needs of Medi-Cal
6beneficiaries are met, the department shall, when evaluating
7performance measures for retention on, addition to, or deletion
8from, the list of performance measures, consider all of the
9following criteria:

10(1) Annual and multiyear Medi-Cal dental fee-for-service
11trended data.

12(2) Other state and national dental program performance and
13quality measures.

14(3) Other state and national performance ratings.

15(d) On October 1, 2014, for the 2013 calendar year, and on or
16before October 1, 2016, for the 2015 calendar year, the list of
17performance measures established by the department along with
18the data of the dental fee-for-service program performance shall
19be posted on the department’s Internet Web site.

20(e) Commencing January 31, 2017, for the 2015-16 fiscal year,
21and annually on or before January 31 for each preceding fiscal
22year thereafter, the list of performance measures established by
23the department along with the data of the dental fee-for-service
24program shall be posted on the department’s Internet Web site.

25(f) Commencing April 30, 2017, for the July 2016 to September
262016, inclusive, fiscal quarter, and quarterly thereafter on or before
27April 30, July 31, October 31, and January 31 for the fiscal quarter
28ending seven months prior, the data of the dental fee-for-service
29program performance shall be posted on the department’s Internet
30Web site.

31(g) The department may amend or remove performance
32measures and establish additional performance measures in
33accordance with all of the following:

34(1) The department shall consider performance measures
35established by other states, the federal government, and national
36organizations developing dental program performance and quality
37measures.

38(2) The department shall notify a fee-for-service contractor, at
39least 30 days prior to the implementation date, of any updates or
40changes to performance measures. The department shall also post
P5    1these updates or changes on its Internet Web site at least 30 days
2prior to implementation in order to maintain transparency to the
3public.

4(3) In establishing the performance measures, the department
5shall consult with stakeholders, including representatives from
6counties, local dental societies, nonprofit entities, legal aid entities,
7and other interested parties.

8(h) The department shall annually prepare a summary report of
9the nature and types of complaints and grievances regarding access
10to, and quality of, dental services, including the outcome.
11Commencing January 31, 2017, for the prior fiscal year, and
12annually thereafter, for each preceding fiscal year, this report shall
13be posted on the department’s Internet Web site.

14(i) The department shall ensure, to the greatest degree possible,
15that the categories of data and performance measures selected
16under this section are consistent with the categories of data and
17performance measures selected under Section 14459.6.

18

SEC. 2.  

Article 4.10 (commencing with Section 14149.8) is
19added to Chapter 7 of Part 3 of Division 9 of the Welfare and
20Institutions Code
, to read:

21 

22Article 4.10.  Medi-Cal Dental Program
23

 

24

14149.8.  

(a) The department shall expedite the enrollment of
25Medi-Cal dental providers by streamlining the Medi-Cal provider
26enrollment process. The department shall pursue all of the
27following activities, to the extent permitted by federal law:

28(1) Create a dental-specific enrollment form.

29(2) Pursue an alternative automatic enrollment process for a
30provider already commercially credentialed by either a dental
31fee-for-service contractor or an administrative services contractor
32for the purpose of providing services as a commercial provider.

33(3) Discontinue requiring providers to resubmit an enrollment
34application that has been deemed incomplete if the missing
35information is available elsewhere within the application packet.

36(4) To the extent that the department expedites the enrollment
37of Medi-Cal dental providers by streamlining the Medi-Cal
38provider enrollment process, the department shall publish the
39criteria for those processes in applicable provider bulletins and
40manuals.

P6    1(b) begin insert(1)end insertbegin insertend insert The department shall maintain the provider network by
2disenrolling a billing and rendering provider whobegin delete has not
3participated in the dental program, as determined by the
4department, for more than a continuous one-year period. Inend delete
begin insert has
5not, over a continuous 12-month period, submitted a claim for
6reimbursement for services rendered.end insert

begin insert

7
(2) Prior to disenrolling a provider described in paragraph (1),
8the department shall send a notice to the provider that the provider
9shall be disenrolled from the dental program six months after the
10date of the notice. The department shall not disenroll a provider
11pursuant to paragraph (1) until six months after the date of that
12notice.

end insert

13begin insert (3)end insertbegin insertend insertbegin insertInend insert order to improve the quality of the dental provider
14network, the department also shall exercise additional measures
15as appropriate and permitted by law, including, but not limited to,
16temporary suspensions.

17(c) (1) The department shall monitor access and utilization of
18Medi-Cal dental services in the fee-for-service and managed care
19delivery systems to assess opportunities to improve access and
20utilization.

21(2) The department shall assess opportunities to develop and
22implement innovative payment reform proposals within the
23Medi-Cal dental programs.

24(d) The department shall explore additional opportunities to
25improve the Medi-Cal Dental Program, in consultation with
26stakeholders and as deemed appropriate by the department and to
27the extent permitted by federal law, including, but not limited to,
28the following:

29(1) Aligning the provision of dental anesthesia services with
30that of medical anesthesia services, including the ability to bill for
31applicable facility fees and ancillary services.

32(2) Adjusting other utilization controls for specialty services,
33as appropriate, to promote access to care while still protecting
34program integrity.

35(3)  Expanding the scope of beneficiary outreach activities
36required by an entity that is contracted with the department to more
37broadly address underutilization throughout the state.

38(e) Prior to implementing an action pursuant to subdivision (g),
39the department shall post the proposed action on its Internet Web
40site at least 30 days before implementation.

P7    1(f) The department shall work with dental managed care plans
2that contract with the department for the purposes of implementing
3the Medi-Cal Dental Program, which includes, but is not limited
4to, contracts authorized pursuant to Sectionsbegin delete 14104.3, Sectionsend delete
5 14087.46, 14089, and 14104.3,begin delete and 14089,end delete to provide beneficiaries
6with access to plan liaisons to assist in the coordination of care for
7enrolled members.

8(g) A Medi-Cal managed care health plan shall do all of the
9following:

10(1) Provide dental screenings for every eligible beneficiary as
11a part of the beneficiary’s initial health assessment.

12(2) Ensure that an eligible beneficiary is referred to an
13appropriate Medi-Cal dental provider.

14(3) Identify plan liaisons available to dental managed care
15contractors and dental fee-for-service contractors to assist in
16coordination of care.

17(h) (1) To increase the efficiency and timeliness of changes,
18any contract amendment, modification, or change order to any
19contract entered into by the department for the purposes of
20implementing the state Medi-Cal Dental Program shall be exempt,
21except as provided in paragraph (2), from Part 2 (commencing
22with Section 10100) of Division 2 of the Public Contract Code, as
23well as Sections 11545 and 11546 of the Government Code, in
24addition to any policies, procedures, or regulations authorized by
25those provisions.

26(2) Paragraph (1) shall not exempt the department from
27establishing a competitive bid process for awarding new contracts
28pursuant to Section 14104.3, as well as for awarding new dental
29contracts pursuant to Sections 14087.46 and 14089.

30(i) Prior to implementing any change pursuant to this section,
31the department shall consult with, and provide notification to,
32stakeholders, including representatives from counties, local dental
33societies, nonprofit entities, legal aid entities, and other interested
34parties.

35(j) Notwithstanding Chapter 3.5 (commencing with Section
3611340) of Part 1 of Division 3 of Title 2 of the Government Code,
37the department, without taking any further regulatory action, shall
38implement, interpret, or make specific policies and procedures
39pertaining to the dental fee-for-service program and dental managed
40care plans, as well as applicable federal waivers and state plan
P8    1amendments, including the provisions set forth in this section, by
2means of all-county letters, plan letters, plan or provider bulletins,
3or similar instructions until regulations are adopted. Thereafter,
4the department shall adopt regulations in accordance with the
5requirements of Chapter 3.5 (commencing with Section 11340) of
6Part 1 of Division 3 of Title 2 of the Government Code. Beginning
7six months after the effective date of this section, and
8notwithstanding Section 10231.5 of the Government Code, the
9department shall provide a status report to the Legislature on a
10semiannual basis until regulations have been adopted.

11(k) This section shall be implemented only to the extent that all
12of the following occur:

13(1) The department obtains any federal approvals necessary to
14implement this section.

15(2) The department obtains federal matching funds to the extent
16permitted by federal law.

17(3) The department receives an appropriation in the annual
18Budget Act each fiscal year for the specific purpose of
19implementing this section.

20

SEC. 3.  

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

22

14459.6.  

(a) The department shall establish a list of
23performance measures to ensure dental health plans meet quality
24criteria required by the department. The list shall specify the
25benchmarks used by the department to determine whether and the
26extent to which a dental health plan meets each performance
27measure. Commencing January 1, 2013, and quarterly thereafter,
28the list of performance measures established by the department
29along with each plan’s performance shall be posted on the
30department’s Internet Web site. The Department of Managed
31Health Care and the advisory committee established pursuant to
32Section 14089.08 shall have access to all performance measures
33and benchmarks used by the department as described in this
34section.

35(1) Commencing April 30, 2017, the quarterly reporting required
36by this subdivision shall be posted in the following manner:

37(A) On or before April 30, 2017, the reporting shall be posted
38for the July 2016 to Septemberbegin delete 2016end deletebegin insert 2016,end insert inclusive, fiscal quarter.

P9    1(B) After April 30, 2017, the reporting shall be posted on a
2quarterly basis on or before April 30, July 31, October 31, and
3January 31 for the fiscal quarter ending seven months prior.

4(2) The performance measures established by the department
5shall include, but not be limited to, all of the following: provider
6network adequacy, overall utilization of dental services, annual
7dental visits,begin insert the total number of patients seen on a per-provider
8basis and the total number of dental services rendered by each
9provider during each calendar year,end insert
use of preventive dental
10services, use of dental treatment services, use of examinations and
11oral health evaluations, sealant to restoration ratio, filling to
12preventive services ratio, treatment to caries prevention ratio, use
13of dental sealants, use of diagnostic services, and survey of member
14satisfaction with plans and providers.

15(3) The survey of member satisfaction with plans and providers
16shall be the same dental version of the Consumer Assessment of
17Healthcare Providers and Systems (CAHPS) survey as used by
18the Healthy Families Program.

19(4) The department shall notify dental health plans at least 30
20days prior to the implementation date of these performance
21measures.

22(5) The department shall include the initial list of performance
23measures and benchmarks in any dental health contracts entered
24into between the department and a dental health plan pursuant to
25Section 14204.

26(6) The department shall update performance measures and
27benchmarks and establish additional performance measures and
28benchmarks in accordance with all of the following:

29(A) The department shall consider performance measures and
30benchmarks established by other states, the federal government,
31and national organizations developing dental program performance
32and quality measures.

33(B) The department shall notify dental health plans at least 30
34days prior to the implementation date of updates or changes to
35performance measures and benchmarks. The department shall also
36post these updates or changes on its Internet Web site at least 30
37days prior to implementation in order to provide transparency to
38the public.

39(C) To ensure that the dental health needs of Medi-Cal
40beneficiaries are met, the department shall, when evaluating
P10   1performance measures and benchmarks for retention on, addition
2to, or deletion from the list, consider all of the following criteria:

3(i) Monthly, quarterly, annual, and multiyear Medi-Cal dental
4managed care trended data.

5(ii) County and statewide Medi-Cal dental fee-for-service
6performance and quality ratings.

7(iii) Other state and national dental program performance and
8quality measures.

9(iv) Other state and national performance ratings.

10(b) In establishing and updating the performance measures and
11benchmarks, the department shall consult the advisory committee
12established pursuant to Section 14089.08, as well as dental health
13plan representatives and other stakeholders, including
14representatives from counties, local dental societies, nonprofit
15entities, legal aid entities, and other interested parties.

16(c) In evaluating a dental health plan’s ability to meet the criteria
17established through the performance measures and benchmarks,
18the department shall select specific performance measures from
19those established by the department in subdivision (a) as the basis
20for establishing financial or other incentives or disincentives,
21including, but not limited to, bonuses, payment withholds, and
22adjustments to beneficiary assignment to plan algorithms. These
23incentives and disincentives shall be included in the dental health
24plan contracts.

25(d) (1) The department shall designate an external quality
26review organization (EQRO) that shall conduct external quality
27reviews for any dental health plan contracting with the department
28pursuant to Section 14204.

29(2) As determined by the department, but at least annually,
30dental health plans shall arrange for an external quality of care
31review with the EQRO designated by the department that evaluates
32the dental health plan’s performance in meeting the performance
33measures established in this section. Dental health plans shall
34cooperate with and assist the EQRO in this review. The Department
35of Managed Health Care shall have direct access to all external
36quality of care review information upon request to the department.

37(3) An external quality of care review shall include, but not be
38limited to, all of the following: performance on the selected
39performance measures and benchmarks established and updated
40by the department, the CAHPS member or consumer satisfaction
P11   1survey referenced in paragraph (2) of subdivision (a), reporting
2systems, and methodologies for calculating performance measures.
3An external quality of care review that includes all of the above
4components shall be paid for by the dental health plan and posted
5online annually, or at any other frequency specified by the
6department, on the department’s Internet Web site.

7(e) All marketing methods and activities to be used by dental
8plans shall comply with subdivision (b) of Section 10850, Sections
914407.1, 14408, 14409, 14410, and 14411, and Title 22 of the
10California Code of Regulations, including Sections 53880 and
1153881. Each dental plan shall submit its marketing plan to the
12department for review and approval.

13(f) Each dental plan shall submit its member services procedures,
14beneficiary informational materials, and any updates to those
15procedures or materials to the department for review and approval.
16The department shall ensure that member services procedures and
17beneficiary informational materials are clear and provide timely
18and fair processes for accepting and acting upon complaints,
19grievances, and disenrollment requests, including procedures for
20appealing decisions regarding coverage or benefits.

21(g) Each dental plan shall submit its provider compensation
22agreements to the department for review and approval.

23(h) The department shall post to its Internet Web site a copy of
24all final reports completed by the Department of Managed Health
25Care regarding dental managed care plans.

26(i) The department shall ensure, to the greatest degree possible,
27that the categories of data and performance measures selected
28under this section are consistent with the categories of data and
29performance measures selected under Section 14132.915.



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