Amended in Senate August 15, 2016

Amended in Senate June 28, 2016

Amended in Senate June 9, 2016

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, to add Sections 14184.72, 14184.73, 14184.74, and 14184.75 to, 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 any necessary federal approvals and federal matching funds.

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 performance measures to the lists for both the dental fee-for-service program and dental plans described above, as specified. 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.begin insert The bill would require the department, no sooner than July 1, 2019, to annually publish specified utilization data for both the dental fee-for-service and dental managed care programsend insertbegin insert from the preceding calendar year and to make this information available on its Internet Web site.end insert

begin delete

SB 815 of the 2015-16 Regular Session, if enacted, would establish

end delete

begin insert Existing law establishesend insert the Medi-Cal 2020 Demonstration Project Act, under which the department is required to implement specified components of a Medicaid 1115(a) demonstration project, referred to as California’s Medi-Cal 2020 demonstration project, consistent with the Special Terms and Conditions approved by the federal Centers for Medicare and Medicaid Services (CMS).begin delete AB 1568 of the 2015-16 Regular Session, if enacted, would requireend deletebegin insert Existing law requiresend insert the department to implement the Dental Transformation Initiative (DTI), a component of the Medi-Cal 2020 demonstration project, under which DTI incentive payments, as defined, within specified domain categories would be made available to qualified providers who meet achievements within one or more of the project domains, and would require the department to evaluate the DTI as required under the Special Terms and Conditions.

This bill would require, consistent with the Special Terms and Conditions and the evaluation requirement described above, the department’s reports of data and quality measures submitted to CMS and made publicly available for each of the domain areas under the DTI to include specified information.

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

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

P3    1

SECTION 1.  

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

3

14132.915.  

(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
8treatment.

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.

P4    1(B) For each provider, all of the following:

2(i) Number of annual dental visits.

begin delete

3(ii) Number of patients seen during the calendar year.

end delete
begin delete

4(iii)

end delete

5begin insert(ii)end insert Number of annual preventive dental services.

begin delete

6(iv)

end delete

7begin insert(iii)end insert Number of annual dental treatment services.

begin delete

8(v)

end delete

9begin insert(iv)end insert Number of annual examinations and oral health evaluations.

10(C) Number of applications of dental sealants and fluoride
11 varnishes.

12(D) Continuity of care and overall utilization over an extended
13period of time.

14(E) All of the following ratios:

15(i) Sealant to restoration.

16(ii) Filling to preventive services.

17(iii) Treatment to caries prevention.

18(F) begin deleteNumber end deletebegin insertNo sooner than January 1, 2018, number end insertof
19beneficiaries requiring general anesthesia to perform procedures.

20(4) The performance measures established by the department
21to monitor the dental fee-for-service program for adults shall
22include, but not be limited to, all of the following:

23(A) Overall utilization of dental services.

24(B) For each provider, all of the following:

25(i) Number of annual dental visits.

begin delete

26(ii) Number of patients seen during the calendar year.

end delete
begin delete

27(iii)

end delete

28begin insert(end insertbegin insertii)end insert Number of annual preventive dental services.

begin delete

29(iv)

end delete

30begin insert(iii)end insert Number of annual dental treatment services.

begin delete

31(v)

end delete

32begin insert(iv)end insert Number of annual examinations and oral health evaluations.

33(C) Treatment to caries prevention ratio.

34(5) The performance measures shall be reported as aggregate
35numbers and as percentages, if appropriate, using standards that
36are as equivalent to those used by managed care entities as feasible.
37Performance measures for the dental fee-for-service program for
38children shall be reported by age groupings if appropriate.

39(b) The department shall include the initial list of performance
40 measures in any dental contract entered into between the
P5    1department and a fee-for-service contractor on or after enactment
2of this section.

3(c) To ensure that the dental health needs of Medi-Cal
4beneficiaries are met, the department shall, when evaluating
5performance measures for retention on, addition to, or deletion
6from, the list of performance measures, consider all of the
7following criteria:

8(1) Annual and multiyear Medi-Cal dental fee-for-service
9trended data.

10(2) Other state and national dental program performance and
11quality measures.

12(3) Other state and national performance ratings.

13(d) On October 1, 2014, for the 2013 calendar year, and on or
14before October 1, 2016, for the 2015 calendar year, the list of
15performance measures established by the department along with
16the data of the dental fee-for-service program performance shall
17be posted on the department’s Internet Web site.

18(e) Commencing January 31, 2017, for the 2015-16 fiscal year,
19and annually on or before January 31 for each preceding fiscal
20year thereafter, the list of performance measures established by
21the department along with the data of the dental fee-for-service
22program shall be posted on the department’s Internet Web site.

23(f) Commencing April 30, 2017, for the July 2016 to September
242016, inclusive, fiscal quarter, and quarterly thereafter on or before
25April 30, July 31, October 31, and January 31 for the fiscal quarter
26ending seven months prior, the data of the dental fee-for-service
27program performance shall be posted on the department’s Internet
28Web site.

29(g) The department may amend or remove performance
30measures and establish additional performance measures in
31accordance with all of the following:

32(1) The department shall consider performance measures
33established by other states, the federal government, and national
34organizations developing dental program performance and quality
35measures.

36(2) The department shall notify a fee-for-service contractor, at
37least 30 days prior to the implementation date, of any updates or
38changes to performance measures. The department shall also post
39these updates or changes on its Internet Web site at least 30 days
P6    1prior to implementation in order to maintain transparency to the
2public.

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

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

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

begin insert

17
(j) No sooner than July 1, 2019, the department shall annually
18publish utilization data from the preceding calendar year and post
19this material on its Internet Web site. The utilization data shall be
20made publicly available for both the dental fee-for-service and
21dental managed care programs. The utilization data shall include
22all of the following information:

end insert
begin insert

23
(1) Number of patients seen on a per-provider basis.

end insert
begin insert

24
(2) Number of annual preventative dental services, dental
25treatment services, examinations, and oral health evaluations
26rendered by each provider during each calendar year.

end insert
begin insert

27
(3) Number of beneficiaries who received general anesthesia
28services.

end insert
29

SEC. 2.  

Article 4.10 (commencing with Section 14149.8) is
30added to Chapter 7 of Part 3 of Division 9 of the Welfare and
31Institutions Code
, to read:

32 

33Article 4.10.  Medi-Cal Dental Program
34

 

35

14149.8.  

(a) The department shall expedite the enrollment of
36Medi-Cal dental providers by streamlining the Medi-Cal provider
37enrollment process. The department shall pursue and implement
38all of the following activities, to the extent permitted by federal
39law:

40(1) Create a dental-specific enrollment form.

P7    1(2) Pursue an alternative automatic enrollment process for a
2provider already commercially credentialed by either a dental
3fee-for-service contractor or an administrative services contractor
4for the purpose of providing services as a commercial provider.

5(3) Discontinue requiring providers to resubmit an enrollment
6application that has been deemed incomplete if the missing
7information is available elsewhere within the application packet.

8(4) To the extent that the department expedites the enrollment
9of Medi-Cal dental providers by streamlining the Medi-Cal
10provider enrollment process, the department shall publish the
11criteria for those processes in applicable provider bulletins and
12manuals.

13(b) (1) The department shallbegin delete continuouslyend delete maintain the provider
14networkbegin delete by disenrollingend deletebegin insert on a monthly basis by deactivatingend insert a billing
15begin delete and renderingend delete provider who has not, over a continuous 12-month
16period, submitted a claim for reimbursement for services rendered.

17(2) Prior tobegin delete disenrollingend deletebegin insert deactivatingend insert a provider described in
18paragraph (1), the department shall send a notice to the provider
19begin insert informing the providerend insert that the provider shall bebegin delete disenrolledend delete
20begin insert deactivatedend insert from the dental programbegin insert unless the provider requests
21reactivation withinend insert
six months after the date of the notice. The
22department shall not disenroll a providerbegin delete pursuant to paragraph
23(1)end delete
until six months after the date of that notice.begin insert This paragraph
24shall not be implemented until the date the department implements
25and programs the necessary system changes to the California
26Dental Medicaid Management Information Systems to implement
27this paragraph, or no sooner than July 1, 2017, whichever is later.end insert

28 (3) In order to improve the quality of the dental provider
29network, the department also shall exercise additional measures
30as appropriate and permitted by law, including, but not limited to,
31 temporary suspensions. The parameters and criteria developed by
32 the department for additional measures forbegin insert deactivations andend insert
33 disenrollments shall be published in applicable provider bulletins
34and manuals.

35(c) (1) The department shall monitor access and utilization of
36Medi-Cal dental services in the fee-for-service and managed care
37delivery systems to assess opportunities to improve access and
38utilization, including an annual review of the treatment
39authorization review process.

P8    1(2) The department shall assess opportunities to develop and
2implement innovative payment reform proposals within the
3Medi-Cal dental programs.

4(d) The department shall explore additional opportunities to
5improve the Medi-Cal Dental Program, in consultation with
6stakeholders and as deemed appropriate by the department and to
7the extent permitted by federal law, including, but not limited to,
8the following:

9(1) Aligning the provision of dental anesthesia services with
10that of medical anesthesia services, including the ability to bill for
11applicable facility fees and ancillary services.

12(2) Adjusting other utilization controls for specialty services,
13as appropriate, to promote access to care while still protecting
14program integrity.

15(3) Expanding the scope of beneficiary outreach activities
16required by an entity that is contracted with the department to more
17broadly address underutilization throughout the state.

18(e) Prior to implementing an action pursuant to subdivision (d),
19the department shall post the proposed action on its Internet Web
20site at least 30 days before implementation.

21(f) The department shall work with dental managed care plans
22that contract with the department for the purposes of implementing
23the Medi-Cal Dental Program, which includes, but is not limited
24to, contracts authorized pursuant to Sections 14087.46, 14089, and
2514104.3, to provide beneficiaries with access to dental plan liaisons
26to assist in the coordination of care for enrolled members.

27(g) A Medi-Cal managed care health plan shall do all of the
28following:

29(1) Provide dental screenings for every eligible beneficiary as
30a part of the beneficiary’s initial health assessment.

31(2) Ensure that an eligible beneficiary is referred to an
32appropriate Medi-Cal dental provider.

33(3) Identify plan liaisons available to dental managed care
34contractors and dental fee-for-service contractors to assist with
35referrals to health plan covered services.

36(h) (1) To increase the efficiency and timeliness of changes,
37any contract amendment, modification, or change order to any
38contract entered into by the department for the purposes of
39implementing the state Medi-Cal Dental Program shall be exempt,
40except as provided in paragraph (2), from Part 2 (commencing
P9    1with Section 10100) of Division 2 of the Public Contract Code, as
2well as Sections 11545 and 11546 of the Government Code, in
3addition to any policies, procedures, or regulations authorized by
4those provisions.

5(2) Paragraph (1) shall not exempt the department from
6establishing a competitive bid process for awarding new contracts
7pursuant to Section 14104.3, as well as for awarding new dental
8contracts pursuant to Sections 14087.46 and 14089.

9(i) Prior to implementing any change pursuant to this section,
10the department shall consult with, and provide notification to,
11stakeholders, including representatives from counties, local dental
12societies, nonprofit entities, legal aid entities, and other interested
13parties.

14(j) (1) Notwithstanding Chapter 3.5 (commencing with Section
1511340) of Part 1 of Division 3 of Title 2 of the Government Code,
16the department, without taking any further regulatory action, shall
17implement, interpret, or make specific policies and procedures
18pertaining to the dental fee-for-service program and dental managed
19care plans, as well as applicable federal waivers and state plan
20amendments, including the provisions set forth in this section, by
21means of all-county letters, plan letters, plan or provider bulletins,
22or similar instructions until regulations are adopted.

23(2) No later than December 31, 2018, the department shall adopt
24regulations in accordance with the requirements of Chapter 3.5
25(commencing with Section 11340) of Part 1 of Division 3 of Title
262 of the Government Code. Beginning six months after the effective
27date of this section, and notwithstanding Section 10231.5 of the
28Government Code, the department shall provide a status report to
29the Legislature on a semiannual basis until regulations have been
30adopted.

31(k) This section shall be implemented only to the extent that all
32of the following occur:

33(1) The department obtains any federal approvals necessary to
34implement this section.

35(2) The department obtains federal matching funds to the extent
36permitted by federal law.

begin delete
37

SEC. 3.  

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

39

14459.6.  

(a) The department shall establish a list of
40performance measures to ensure dental health plans meet quality
P10   1criteria required by the department. The list shall specify the
2benchmarks used by the department to determine whether and the
3extent to which a dental health plan meets each performance
4measure. Commencing January 1, 2013, and quarterly thereafter,
5the list of performance measures established by the department
6along with each plan’s performance shall be posted on the
7department’s Internet Web site. The Department of Managed
8Health Care and the advisory committee established pursuant to
9Section 14089.08 shall have access to all performance measures
10and benchmarks used by the department as described in this
11section.

12(1) Commencing April 30, 2017, the quarterly reporting required
13by this subdivision shall be posted in the following manner:

14(A) On or before April 30, 2017, the reporting shall be posted
15for the July 2016 to September 2016, inclusive, fiscal quarter.

16(B) After April 30, 2017, the reporting shall be posted on a
17quarterly basis on or before April 30, July 31, October 31, and
18January 31 for the fiscal quarter ending seven months prior.

19(2) The performance measures established by the department
20shall include, but not be limited to, all of the following: provider
21network adequacy, overall utilization of dental services, annual
22dental visits, the total number of patients seen on a per-provider
23basis and the total number of dental services rendered by each
24provider during each calendar year, use of preventive dental
25services, use of dental treatment services, use of examinations and
26oral health evaluations, sealant to restoration ratio, filling to
27preventive services ratio, treatment to caries prevention ratio, use
28of dental sealants, use of diagnostic services, use of general
29anesthesia for dental services, and survey of member satisfaction
30with plans and providers.

31(3) The survey of member satisfaction with plans and providers
32shall be the same dental version of the Consumer Assessment of
33Healthcare Providers and Systems (CAHPS) survey as used by
34the Healthy Families Program.

35(4) The department shall notify dental health plans at least 30
36days prior to the implementation date of these performance
37measures.

38(5) The department shall include the initial list of performance
39measures and benchmarks in any dental health contracts entered
P11   1into between the department and a dental health plan pursuant to
2Section 14204.

3(6) The department shall update performance measures and
4benchmarks and establish additional performance measures and
5benchmarks in accordance with all of the following:

6(A) The department shall consider performance measures and
7benchmarks established by other states, the federal government,
8and national organizations developing dental program performance
9and quality measures.

10(B) The department shall notify dental health plans at least 30
11days prior to the implementation date of updates or changes to
12performance measures and benchmarks. The department shall also
13post these updates or changes on its Internet Web site at least 30
14days prior to implementation in order to provide transparency to
15the public.

16(C) To ensure that the dental health needs of Medi-Cal
17beneficiaries are met, the department shall, when evaluating
18performance measures and benchmarks for retention on, addition
19to, or deletion from the list, consider all of the following criteria:

20(i) Monthly, quarterly, annual, and multiyear Medi-Cal dental
21managed care trended data.

22(ii) County and statewide Medi-Cal dental fee-for-service
23performance and quality ratings.

24(iii) Other state and national dental program performance and
25quality measures.

26(iv) Other state and national performance ratings.

27(b) In establishing and updating the performance measures and
28benchmarks, the department shall consult the advisory committee
29established pursuant to Section 14089.08, as well as dental health
30plan representatives and other stakeholders, including
31representatives from counties, local dental societies, nonprofit
32entities, legal aid entities, and other interested parties.

33(c) In evaluating a dental health plan’s ability to meet the criteria
34established through the performance measures and benchmarks,
35the department shall select specific performance measures from
36those established by the department in subdivision (a) as the basis
37for establishing financial or other incentives or disincentives,
38including, but not limited to, bonuses, payment withholds, and
39adjustments to beneficiary assignment to plan algorithms. These
P12   1incentives and disincentives shall be included in the dental health
2plan contracts.

3(d) (1) The department shall designate an external quality
4review organization (EQRO) that shall conduct external quality
5reviews for any dental health plan contracting with the department
6pursuant to Section 14204.

7(2) As determined by the department, but at least annually,
8dental health plans shall arrange for an external quality of care
9review with the EQRO designated by the department that evaluates
10the dental health plan’s performance in meeting the performance
11measures established in this section. Dental health plans shall
12cooperate with and assist the EQRO in this review. The Department
13of Managed Health Care shall have direct access to all external
14quality of care review information upon request to the department.

15(3) An external quality of care review shall include, but not be
16limited to, all of the following: performance on the selected
17performance measures and benchmarks established and updated
18by the department, the CAHPS member or consumer satisfaction
19survey referenced in paragraph (2) of subdivision (a), reporting
20systems, and methodologies for calculating performance measures.
21An external quality of care review that includes all of the above
22components shall be paid for by the dental health plan and posted
23online annually, or at any other frequency specified by the
24department, on the department’s Internet Web site.

25(e) All marketing methods and activities to be used by dental
26plans shall comply with subdivision (b) of Section 10850, Sections
2714407.1, 14408, 14409, 14410, and 14411, and Title 22 of the
28California Code of Regulations, including Sections 53880 and
2953881 of Title 22 of the California Code of Regulations. Each
30dental plan shall submit its marketing plan to the department for
31review and approval.

32(f) Each dental plan shall submit its member services procedures,
33beneficiary informational materials, and any updates to those
34procedures or materials to the department for review and approval.
35The department shall ensure that member services procedures and
36beneficiary informational materials are clear and provide timely
37and fair processes for accepting and acting upon complaints,
38grievances, and disenrollment requests, including procedures for
39appealing decisions regarding coverage or benefits.

P13   1(g) Each dental plan shall submit its provider compensation
2agreements to the department for review and approval.

3(h) The department shall post to its Internet Web site a copy of
4all final reports completed by the Department of Managed Health
5Care regarding dental managed care plans.

6(i) The department shall ensure, to the greatest degree possible,
7that the categories of data and performance measures selected
8under this section are consistent with the categories of data and
9performance measures selected under Section 14132.915.

end delete
10

begin deleteSEC. 4.end delete
11
begin insertSEC. 3.end insert  

Section 14184.72 is added to the Welfare and
12Institutions Code
, immediately following Section 14184.71, to
13read:

14

14184.72.  

In connection with the evaluation of the DTI required
15by Section 14184.71, the department’s report of data and quality
16measures submitted to the federal Centers for Medicare and
17Medicaid Services (CMS) and made publicly available pursuant
18to the Special Terms and Conditions for the Increase Preventive
19Services Utilization for Children domain shall include, but not be
20limited to, all of the following:

21(a) A detailed description of how the department has
22operationalized the domain, including information identifying
23which entities have responsibility for the components of the
24domain.

25(b) The number of individual incentives paid and the total
26amount expended under the domain for the current program year.

27(c) An awareness plan that describes all of the following:

28(1) How the department has generated awareness of the
29availability of incentives for providing preventive dental services
30to children, including steps taken to increase awareness of the DTI
31among dental and primary care providers.

32(2) How the department has generated awareness among
33beneficiaries of the availability of, the importance of, and how to
34access preventive dental services for children.

35(3) The different approaches to raising awareness undertaken
36among specific groups, including age groups, rural and urban
37residents, and primary language groups.begin insert These approaches shall
38be developed in conjunction with interested dental and children’s
39health stakeholders.end insert

P14   1(d) Anbegin insert annualend insert analysis of whether the awareness plan described
2in subdivision (c) has succeeded in generating the utilization
3necessary, by subgrouping, to meet the goals of the domain, and
4a description of changes to the awareness plan needed to address
5any identified deficiencies.

6(e) Data describing both of the following:

7(1) The use of, and expenditures on, preventive dental services.

8(2) The use of, and expenditures on, other nonpreventive dental
9services.

10(f) A discussion of the extent to which the metrics described
11for the domain are proving to be useful in understanding the
12effectiveness of the activities undertaken in the domain.

13(g) An analysis of changes in cost per capita.

14(h) A descriptive analysis of program integrity challenges
15generated by the domain and how those challenges have been, or
16will be, addressed.

17(i) A descriptive analysis of the overall effectiveness of the
18activities in the domain in meeting the intended goals of the
19domain, any lessons learned, and any recommended adjustments.

20

begin deleteSEC. 5.end delete
21
begin insertSEC. 4.end insert  

Section 14184.73 is added to the Welfare and
22Institutions Code
, to read:

23

14184.73.  

In connection with the evaluation of the DTI required
24by Section 14184.71, the department’s report of data and quality
25measures submitted to the federal Centers for Medicare and
26Medicaid Services and made publicly available pursuant to the
27Special Terms and Conditions for the Caries Risk Assessment
28(CRA) and Disease Management Pilot domain shall include, but
29not be limited to, all of the following:

30(a) A detailed description of how the department has
31operationalized the domain, including information identifying
32which entities have responsibility for the components of the
33domain.

34(b) The number of individual incentives paid and the total
35amount expended, by county, under the domain in the current
36demonstration year.

37(c) A descriptive assessment of the impact of the domain on
38targeted children in the age ranges of under one year of age, one
39through two years of age, three through four years of age, and five
40through six years of age, for all of the following:

P15   1(1) Provision of CRAs.

2(2) Provision of dental exams.

3(3) Use of, and expenditures on, preventive dental services.

4(4) Use of, and expenditures on, dental treatment services.

5(5) Use of, and expenditures on, dental-related general
6
begin delete anesthesia.end deletebegin insert anesthesia, including facility costs.end insert

7

begin deleteSEC. 6.end delete
8
begin insertSEC. 5.end insert  

Section 14184.74 is added to the Welfare and
9Institutions Code
, to read:

10

14184.74.  

In connection with the evaluation of the DTI required
11by Section 14184.71, the department’s report of data and quality
12measures submitted to the federal Centers for Medicare and
13Medicaid Services and made publicly available pursuant to the
14Special Terms and Conditions for the Increase Continuity of Care
15domain shall include, but not be limited to, all of the following:

16(a) A detailed description of how the department has
17operationalized the domain, including information identifying
18which entities have responsibility for the components of the
19domain.

20(b) The number of individual incentives paid and the total
21amount expended, by county, under the domain in the current
22demonstration year.

23(c) A descriptive assessment of the impact of the domain, with
24respect to targeted children, of all of the following:

25(1) Provision of dental exams.

26(2) Use of, and expenditures on, preventive dental services.

27(3) Use of, and expenditures on, other nonpreventive dental
28services.

29(d) A discussion of the extent to which the metrics prescribed
30for the domain are proving to be useful in understanding the
31effectiveness of the activities undertaken in the domain.

32(e) An analysis of change in cost per capita.

33(f) A descriptive analysis of program integrity challenges
34 generated by the domain and how those challenges have been, or
35will be, addressed.

36(g) A descriptive analysis of the overall effectiveness of the
37activities in the domain in meeting the intended goals of the
38domain, any lessons learned, and any recommended adjustments.

P16   1

begin deleteSEC. 7.end delete
2
begin insertSEC. 6.end insert  

Section 14184.75 is added to the Welfare and
3Institutions Code
, to read:

4

14184.75.  

In connection with the evaluation of the DTI required
5by Section 14184.71, the department’s report of data and quality
6measures submitted to the federal Centers for Medicare and
7Medicaid Services and made publicly available pursuant to the
8Special Terms and Conditions for the Local Dental Pilot Program
9domain shall include, but not be limited to, all of the following:

10(a) A detailed description of how the department has
11operationalizedbegin delete the domain, including information identifying
12which entities have responsibility for the components of the
13domain.end delete
begin insert this aspect of the demonstration project, including the
14solicitation and selection process.end insert

15(b) The number ofbegin delete individual incentives paidend deletebegin insert pilot projects
16fundedend insert
and the total amount expended, bybegin delete county,end deletebegin insert project,end insert under
17the domain in the current demonstration year.

18(c) A description of the pilot projects selected for award that
19for each project shall include, but not be limited to, all of the
20following:

21(1) Specific strategies for the project.

22(2) Target populations.

23(3) Payment methodologies.

24(4) Annual budget for the project.

25(5) Expected duration of the project.

26(6) Performance metrics by which the project shall be measured.

27(7) The intended goal of the project.

28(d) An assessment of the pilot projects selected for award that
29includes for each project all of the following:

30(1) Project performance and outcomes.

31(2) Project replicability.

32(3) Challenges encountered and actions undertaken to address
33those challenges.

34(4) Information on payments made by the department to the
35project.

36(e) A descriptive assessment of the impact of the Local Dental
37Pilot Program domain on achieving the goals of the Increase
38Preventive Services Utilization for Children, Caries Risk
39Assessment and Disease Management Pilot, and Increase
40Continuity of Care domains.

P17   1(f) A descriptive analysis of program integrity challenges
2generated by the domain and how those challenges have been, or
3will be, addressed.

4begin insert

begin insertSEC. 7.end insert  

end insert

begin insertSection 14459.6 of the end insertbegin insertWelfare and Institutions Codeend insert
5
begin insert is amended to read:end insert

6

14459.6.  

(a) The department shall establish a list of
7performance measures to ensure dental health plans meet quality
8criteria required by the department. The list shall specify the
9benchmarks used by the department to determine whether and the
10extent to which a dental health plan meets each performance
11measure. Commencing January 1, 2013, and quarterly thereafter,
12the list of performance measures established by the department
13along with each plan’s performance shall be posted on the
14department’s Internet Web site. The Department of Managed
15Health Care and the advisory committee established pursuant to
16Section 14089.08 shall have access to all performance measures
17and benchmarks used by the department as described in this
18section.

begin insert

19
(1) Commencing April 30, 2017, the quarterly reporting required
20by this subdivision shall be posted in the following manner:

end insert
begin insert

21
(A) On or before April 30, 2017, the reporting shall be posted
22for the July 2016 to September 2016, inclusive, fiscal quarter.

end insert
begin insert

23
(B) After April 30, 2017, the reporting shall be posted on a
24quarterly basis on or before April 30, July 31, October 31, and
25January 31 for the fiscal quarter ending seven months prior.

end insert
begin delete

26(1)

end delete

27begin insert(end insertbegin insert2)end insert The performance measures established by the department
28shall include, but not be limited to, all of the following: provider
29network adequacy, overall utilization of dental services, annual
30dental visits,begin insert the total number of patients seen on a per-provider
31basis and the total number of dental services rendered by each
32provider during each calendar year,end insert
use of preventive dental
33services, use of dental treatment services, use of examinations and
34oral health evaluations, sealant to restoration ratio, filling to
35preventive services ratio, treatment to caries prevention ratio, use
36of dental sealants, use of diagnostic services, and survey of member
37satisfaction with plans and providers.

begin delete

38(2)

end delete

39begin insert(end insertbegin insert3)end insert The survey of member satisfaction with plans and providers
40shall be the same dental version of the Consumer Assessment of
P18   1Healthcare Providers and Systems (CAHPS) survey as used by
2the Healthy Families Program.

begin delete

3(3)

end delete

4begin insert(end insertbegin insert4)end insert The department shall notify dental health plans at least 30
5days prior to the implementation date of these performance
6measures.

begin delete

7(4)

end delete

8begin insert(end insertbegin insert5)end insert 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
11Section 14204.

begin delete

12(5)

end delete

13begin insert(end insertbegin insert6)end insert The department shall update performance measures and
14benchmarks and establish additional performance measures and
15benchmarks in accordance with all of the following:

16(A) The department shall consider performance measures and
17benchmarks established by other states, the federal government,
18and national organizations developing dental program performance
19and quality measures.

20(B) The department shall notify dental health plans at least 30
21days prior to the implementation date of updates or changes to
22performance measures and benchmarks. The department shall also
23post these updates or changes on its Internet Web site at least 30
24days prior to implementation in order to provide transparency to
25the public.

26(C) To ensure that the dental health needs of Medi-Cal
27beneficiaries are met, the department shall, when evaluating
28performance measures and benchmarks for retention on, addition
29to, or deletion from the list, consider all of the following criteria:

30(i) Monthly, quarterly, annual, and multiyear Medi-Cal dental
31managed care trended data.

32(ii) County and statewide Medi-Cal dental fee-for-service
33performance and quality ratings.

34(iii) Other state and national dental program performance and
35quality measures.

36(iv) Other state and national performance ratings.

37(b) In establishing and updating the performance measures and
38benchmarks, the department shall consult the advisory committee
39established pursuant to Section 14089.08, as well as dental health
40plan representatives and other stakeholders, including
P19   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
11plan contracts.

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
38begin delete 53881.end deletebegin insert 53881 of Title 22 of the California Code of Regulations.end insert
39 Each dental plan shall submit its marketing plan to the department
40for review and approval.

P20   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.

begin insert

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.

end insert


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