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
begin delete approvals,end delete federal matching begin delete funds, and an appropriation in the annual Budget Act for the specific purpose of implementing those provisions.end delete
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 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, as of October 31, 2016, 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,
7access, availability, and effectiveness of preventive care and
9(2) Prior to establishing the quality and access criteria described
10in paragraph (1), the department shall consult with stakeholders,
11including representatives from counties, local dental societies,
12nonprofit entities, legal aid entities, and other interested parties.
13(3) The performance
measures established by the department
14to monitor the dental fee-for-service program for children shall
15include, but not be limited to, all of the following:
16(A) Overall utilization of dental services.
17(B) Number of annual dental visits, the total number of patients
18seen, on a per-provider basis, and the total number of preventive
19dental services, dental treatment services, and examinations and
20oral health evaluations rendered by each provider during each
P4 1(C) Number of applications of dental sealants.
2(D) Continuity of care and overall utilization over an extended
3period of time.
4(E) All of the following ratios:
5(i) Sealant to restoration.
6(ii) Filling to preventive services.
7(iii) Treatment to caries prevention.
8(4) The performance measures established by the department
9to monitor the dental fee-for-service program for adults shall
10include, but not be limited to, all of the following:
11(A) Number of annual dental visits and preventive dental
12services, the total number of patients seen on a per-provider basis,
13and the total number of dental services rendered by each provider
14during each calendar year.
15(B) Treatment to caries prevention ratio.
16(5) The performance measures shall be reported as aggregate
17numbers and as percentages, if appropriate, using standards that
18are as equivalent to those used by managed care entities as feasible.
19Performance measures for the dental fee-for-service program for
20children shall be reported by age groupings if appropriate.
21(b) The department shall include the initial list of performance
22 measures in any dental contract entered into between the
23department and a fee-for-service contractor on or after enactment
24of this section.
25(c) To ensure that the dental health needs of Medi-Cal
26beneficiaries are met, the department shall, when evaluating
27performance measures for retention on, addition to, or deletion
28from, the list of performance measures, consider all of the
30(1) Annual and multiyear Medi-Cal dental fee-for-service
32(2) Other state and national dental program performance and
34(3) Other state and national performance ratings.
35(d) On October 1, 2014, for the 2013 calendar year, and on or
36before October 1, 2016, for the 2015 calendar year, the list of
37performance measures established by the department along with
38the data of the dental fee-for-service program performance shall
39be posted on the department’s Internet Web site.
P5 1(e) Commencing January 31, 2017, for the 2015-16 fiscal year,
2and annually on or before January 31 for each preceding fiscal
3year thereafter, the list of performance measures established by
4the department along with the data of the dental fee-for-service
5program shall be posted on the department’s Internet Web site.
6(f) Commencing April 30, 2017, for the July 2016 to September
72016, inclusive, fiscal quarter, and quarterly thereafter on or before
8April 30, July 31, October 31, and January 31 for the fiscal quarter
9ending seven months prior, the data of the dental fee-for-service
10program performance shall be posted on the department’s Internet
12(g) The department may amend or remove performance
13measures and establish additional performance measures in
14accordance with all of the following:
15(1) The department shall consider performance measures
16established by other states, the federal government, and national
17organizations developing dental program performance and quality
19(2) The department shall notify a fee-for-service contractor, at
20least 30 days prior to the implementation date, of any updates or
21changes to performance measures. The department shall also post
22these updates or changes on its Internet Web site at least 30 days
23prior to implementation in order to maintain transparency to the
25(3) In establishing the performance measures, the department
26shall consult with stakeholders, including representatives from
27counties, local dental societies, nonprofit entities, legal aid entities,
28and other interested parties.
29(h) The department shall annually prepare a summary report of
30the nature and types of complaints and grievances regarding access
31to, and quality of, dental services, including the outcome.
32Commencing January 31, 2017, for the prior fiscal year, and
33annually thereafter, for each preceding fiscal year, this report shall
34be posted on the department’s Internet Web site.
35(i) The department shall ensure, to the greatest degree possible,
36that the categories of data and performance measures selected
37under this section are consistent with the categories of data and
38performance measures selected under Section 14459.6.
Article 4.10 (commencing with Section 14149.8) is
2added to Chapter 7 of Part 3 of Division 9 of the Welfare and
3Institutions Code, to read:
(a) The department shall expedite the enrollment of
8Medi-Cal dental providers by streamlining the Medi-Cal provider
9enrollment process. The department shall pursue
10 all of the following activities, to the extent permitted by federal
12(1) Create a dental-specific enrollment form.
13(2) Pursue an alternative automatic enrollment process for a
14provider already commercially credentialed by either a dental
15fee-for-service contractor or an administrative services contractor
16for the purpose of providing services as a commercial provider.
17(3) Discontinue requiring providers to resubmit an enrollment
18application that has been deemed incomplete if the missing
19information is available elsewhere within the application packet.
20(4) To the extent that the department expedites the enrollment
21of Medi-Cal dental providers by streamlining the Medi-Cal
22provider enrollment process, the department shall publish the
23criteria for those processes in applicable provider bulletins and
25(b) (1) The department shall maintain the provider network by
26disenrolling a billing and rendering provider who has not, over a
27continuous 12-month period, submitted a claim for reimbursement
28for services rendered.
29(2) Prior to disenrolling a provider described in paragraph (1),
30the department shall send a notice to the provider that the provider
31shall be disenrolled from the dental program six months after the
32date of the notice. The department shall not disenroll a provider
33pursuant to paragraph (1) until six months after the date of that
35 (3) In order to improve the quality of the dental provider
36network, the department also shall exercise additional measures
37as appropriate and permitted by law, including, but not limited to,
P7 1(c) (1) The department shall monitor access and utilization of
2Medi-Cal dental services in the fee-for-service and managed care
3delivery systems to assess opportunities to improve access and
5(2) The department shall assess opportunities to develop and
6implement innovative payment reform proposals within the
7Medi-Cal dental programs.
8(d) The department shall explore additional opportunities to
9improve the Medi-Cal Dental Program, in consultation with
10stakeholders and as deemed appropriate by the department and to
11the extent permitted by federal law, including, but not limited to,
13(1) Aligning the provision of dental anesthesia services with
14that of medical anesthesia services, including the ability to bill for
15applicable facility fees and ancillary services.
16(2) Adjusting other utilization controls for specialty services,
17as appropriate, to promote access to care while still protecting
19(3) Expanding the scope of beneficiary outreach activities
20required by an entity that is contracted with the department to more
21broadly address underutilization throughout the state.
22(e) Prior to implementing an action pursuant to subdivision
begin delete (g),end delete
23 the department shall post the proposed action on its Internet
24Web site at least 30 days before implementation.
25(f) The department shall work with dental managed care plans
26that contract with the department for the purposes of implementing
27the Medi-Cal Dental Program, which includes, but is not limited
28to, contracts authorized pursuant to Sections 14087.46, 14089, and
2914104.3, to provide beneficiaries with access to plan liaisons
30to assist in the coordination of care for enrolled members.
31(g) A Medi-Cal managed care health plan shall do all of the
33(1) Provide dental screenings for every eligible beneficiary as
34a part of the beneficiary’s initial health assessment.
35(2) Ensure that an eligible beneficiary is referred to an
36appropriate Medi-Cal dental provider.
37(3) Identify plan liaisons available to dental managed care
38contractors and dental fee-for-service contractors to assist
begin delete in
39coordination of care.end delete
3(h) (1) To increase the efficiency and timeliness of changes,
4any contract amendment, modification, or change order to any
5contract entered into by the department for the purposes of
6implementing the state Medi-Cal Dental Program shall be exempt,
7except as provided in paragraph (2), from Part 2 (commencing
8with Section 10100) of Division 2 of the Public Contract Code, as
9well as Sections 11545 and 11546 of the Government Code, in
10addition to any policies, procedures, or regulations authorized by
12(2) Paragraph (1) shall not exempt the department from
13establishing a competitive bid process for awarding new contracts
14pursuant to Section 14104.3, as well as for awarding new dental
15contracts pursuant to Sections 14087.46 and 14089.
16(i) Prior to implementing any change pursuant to this section,
17the department shall consult with, and provide notification to,
18stakeholders, including representatives from counties, local dental
19societies, nonprofit entities, legal aid entities, and other interested
21(j) Notwithstanding Chapter 3.5 (commencing with Section
2211340) of Part 1 of Division 3 of Title 2 of the Government Code,
23the department, without taking any further regulatory action, shall
24implement, interpret, or make specific policies and procedures
25pertaining to the dental fee-for-service program and dental managed
26care plans, as well as applicable federal waivers and state plan
27amendments, including the provisions set forth in this section, by
28means of all-county letters, plan letters, plan or provider bulletins,
29or similar instructions until regulations are adopted.
begin delete Thereafter,end delete
30the department shall adopt
31regulations in accordance with the requirements of Chapter 3.5
32(commencing with Section 11340) of Part 1 of Division 3 of Title
332 of the Government Code. Beginning six months after the effective
34date of this section, and notwithstanding Section 10231.5 of the
35Government Code, the department shall provide a status report to
36the Legislature on a semiannual basis until regulations have been
38(k) This section shall be implemented only to the extent that all
39of the following occur:
P9 1(1) The department obtains any federal approvals necessary to
2implement this section.
3(2) The department obtains federal matching funds to the extent
4permitted by federal law.
5(3) The department receives an appropriation in the annual
6Budget Act each fiscal year for the specific purpose of
7implementing this section.
Section 14459.6 of the Welfare and Institutions Code
9 is amended to read:
(a) The department shall establish a list of
11performance measures to ensure dental health plans meet quality
12criteria required by the department. The list shall specify the
13benchmarks used by the department to determine whether and the
14extent to which a dental health plan meets each performance
15measure. Commencing January 1, 2013, and quarterly thereafter,
16the list of performance measures established by the department
17along with each plan’s performance shall be posted on the
18department’s Internet Web site. The Department of Managed
19Health Care and the advisory committee established pursuant to
20Section 14089.08 shall have access to all performance measures
21and benchmarks used by the department as described in this
23(1) Commencing April 30, 2017, the quarterly reporting required
24by this subdivision shall be posted in the following manner:
25(A) On or before April 30, 2017, the reporting shall be posted
26for the July 2016 to September 2016, inclusive, fiscal quarter.
27(B) After April 30, 2017, the reporting shall be posted on a
28quarterly basis on or before April 30, July 31, October 31, and
29January 31 for the fiscal quarter ending seven months prior.
30(2) The performance measures established by the department
31shall include, but not be limited to, all of the following: provider
32network adequacy, overall utilization of dental services, annual
33dental visits, the total number of patients seen on a per-provider
34basis and the total number of dental services rendered by each
35provider during each calendar year, use of preventive dental
36services, use of dental treatment services, use of examinations and
37oral health evaluations, sealant to restoration ratio, filling to
38preventive services ratio, treatment to caries prevention ratio, use
39of dental sealants, use of diagnostic services, and survey of member
40satisfaction with plans and providers.
P10 1(3) The survey of member satisfaction with plans and providers
2shall be the same dental version of the Consumer Assessment of
3Healthcare Providers and Systems (CAHPS) survey as used by
4the Healthy Families Program.
5(4) The department shall notify dental health plans at least 30
6days prior to the implementation date of these performance
8(5) The department shall include the initial list of performance
9measures and benchmarks in any dental health contracts entered
10into between the department and a dental health plan pursuant to
12(6) The department shall update performance measures and
13benchmarks and establish additional performance measures and
14benchmarks in accordance with all of the following:
15(A) The department shall consider performance measures and
16benchmarks established by other states, the federal government,
17and national organizations developing dental program performance
18and quality measures.
19(B) The department shall notify dental health
plans at least 30
20days prior to the implementation date of updates or changes to
21performance measures and benchmarks. The department shall also
22post these updates or changes on its Internet Web site at least 30
23days prior to implementation in order to provide transparency to
25(C) To ensure that the dental health needs of Medi-Cal
26beneficiaries are met, the department shall, when evaluating
27performance measures and benchmarks for retention on, addition
28to, or deletion from the list, consider all of the following criteria:
29(i) Monthly, quarterly, annual, and multiyear Medi-Cal dental
30managed care trended data.
31(ii) County and statewide Medi-Cal dental fee-for-service
32performance and quality ratings.
33(iii) Other state and national dental program performance and
35(iv) Other state and national performance ratings.
36(b) In establishing and updating the performance measures and
37benchmarks, the department shall consult the advisory committee
38established pursuant to Section 14089.08, as well as dental health
39plan representatives and other stakeholders, including
P11 1representatives from counties, local dental societies, nonprofit
2entities, legal aid entities, and other interested parties.
3(c) In evaluating a dental health plan’s ability to meet the criteria
4established through the performance measures and benchmarks,
5the department shall select specific performance measures from
6those established by the department in subdivision (a) as the basis
7for establishing financial or other incentives or disincentives,
8including, but not limited to, bonuses, payment withholds, and
9adjustments to beneficiary assignment to plan algorithms. These
10incentives and disincentives shall be included in the dental health
12(d) (1) The department shall designate an external quality
13review organization (EQRO) that shall conduct external quality
14reviews for any dental health plan contracting with the department
15pursuant to Section 14204.
16(2) As determined by the department, but at least annually,
17dental health plans shall arrange for an external quality of care
18review with the EQRO designated by the department that evaluates
19the dental health plan’s performance in meeting the performance
20measures established in this section. Dental health plans shall
21cooperate with and assist the EQRO in this review. The Department
22of Managed Health Care shall have direct access to all external
23quality of care review information upon request to the department.
24(3) An external quality of care review shall include, but not be
25limited to, all of the following: performance on the selected
26performance measures and benchmarks established and updated
27by the department, the CAHPS member or consumer satisfaction
28survey referenced in paragraph (2) of subdivision (a), reporting
29systems, and methodologies for calculating performance measures.
30An external quality of care review that includes all of the above
31components shall be paid for by the dental health plan and posted
32online annually, or at any other frequency specified by the
33department, on the department’s Internet Web site.
34(e) All marketing methods and activities to be used by dental
35plans shall comply with subdivision (b) of Section 10850, Sections
3614407.1, 14408, 14409, 14410, and 14411, and Title 22 of the
37California Code of Regulations, including Sections 53880 and
3853881. Each dental plan shall submit its marketing plan to the
39department for review and approval.
P12 1(f) Each dental plan shall submit its member services procedures,
2beneficiary informational materials, and any updates to those
3procedures or materials to the department for review and approval.
4The department shall ensure that member services procedures and
5beneficiary informational materials are clear and provide timely
6and fair processes for accepting and acting upon complaints,
7grievances, and disenrollment requests, including procedures for
8appealing decisions regarding coverage or benefits.
9(g) Each dental plan shall submit its provider compensation
10agreements to the department for review and approval.
11(h) The department shall post to its Internet Web site a copy of
12all final reports completed by the Department of Managed Health
13Care regarding dental managed care plans.
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 14132.915.
immediately following Section 14184.71