BILL ANALYSIS Ó
AB 2207
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Date of Hearing: April 19, 2016
ASSEMBLY COMMITTEE ON HEALTH
Jim Wood, Chair
AB 2207
(Wood) - As Introduced February 18, 2016
SUBJECT: Medi-Cal: dental program.
SUMMARY: Makes changes to the Medi-Cal dental program
(Denti-Cal) provider enrollment and disenrollment process,
increases access and utilization oversight responsibility of the
Department of Health Care Services (DHCS) over Denti-Cal
contracts, and aligns Denti-Cal fee-for-service (FFS) and Dental
managed care (DMC) annual and quarterly data reporting
requirements. Specifically, this bill:
1)Requires DHCS to expedite the enrollment of Denti-Cal
providers by streamlining the Medi-Cal provider enrollment
process through the following activities:
a) Create a dental-specific enrollment form;
b) Pursue an alternative automatic enrollment process for a
provider already commercially credentialed by either a
dental FFS contractor or an administrative services
contractor for the purpose of providing services as a
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commercial provider;
c) Discontinue requiring providers to resubmit an
enrollment application that has been deemed incomplete if
the missing information is available elsewhere within the
application packet; and,
d) Require DHCS to publish the criteria to expedite the
enrollment of Denti-Cal providers in applicable provider
bulletins and manuals.
2)Requires DHCS to disenroll a provider who has not participated
in the dental program, as determined by DHCS, for more than a
continuous one-year period. Permits DHCS to exercise
additional measures as appropriate in order to improve the
quality of the dental provider network, including, but not
limited to, temporary suspensions.
3)Requires DHCS to monitor access and utilization of Denti-Cal
services in the FFS and DMC delivery systems to assess
opportunities to improve access and utilization and assess
opportunities to develop and implement innovative payment
reform proposals within Denti-Cal.
4)Requires DHCS to explore additional opportunities in
consultation with stakeholders, to improve the Denti-Cal,
including, but not limited to, the following:
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a) Aligning the provision of dental anesthesia services
with that of medical anesthesia services, including the
ability to bill for applicable facility fees and ancillary
services;
b) Adjusting other utilization controls for specialty
services, as appropriate, to promote access to care while
still protecting program integrity; and,
c) Expanding the scope of beneficiary outreach activities
required by an entity that is contracted with the
department to more broadly address underutilization
throughout the state.
5)Requires DHCS to work with DMC plans that contract with DHCS
for the purposes of implementing the Denti-Cal to provide
beneficiaries with access to plan liaisons to assist in the
coordination of care for enrolled members.
6)Requires a Medi-Cal managed care health plan to do all of the
following:
a) Provide dental screenings for every eligible beneficiary
as a part of the beneficiary's initial health assessment;
b) Ensure that an eligible beneficiary is referred to an
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appropriate Medi-Cal dental provider; and,
c) Identify plan liaisons available to DMC contractors and
dental FFS contractors to assist in coordination of care.
7)Requires DHCS to post any proposed action on its Internet
Website at least 30 days prior to implementing an action as
required in 6) above.
8)Exempts any amendments, modifications or changes to Denti-Cal
contracts entered into by DHCS from certain contracting
provisions in order to increase the efficiency and timeliness
of changes. Specifies that these exemptions do not exempt
DHCS from establishing a competitive bid process for awarding
new Denti-Cal contracts.
9)Requires DHCS to consult with, and provide notification to,
stakeholders, including representatives from counties, local
dental societies, nonprofit entities, legal aid entities, and
other interested parties prior to implementation of new
requirements.
10)Permits DHCS to implement, interpret, or make specific
policies and procedures pertaining to the dental FFS program
and DMC plans, as well as applicable federal waivers and state
plan amendments, by means of all-county letters, plan letters,
plan or provider bulletins, or similar instructions until
regulations are adopted. Requires thereafter DHCS to adopt
regulations in accordance with the requirements of the
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Administrative Procedures Act.
11)Requires DHCS to provide a status report to the Legislature
six months after the effective date of the statute and on a
semiannual basis thereafter until regulations have been
adopted.
12)Makes the implementation of this bill conditional upon DHCS
obtaining any federal approvals necessary, any federal
matching funds to the extent permitted by federal law, and an
appropriation in the annual Budget Act each fiscal year.
13)Requires the list of performance measures established by DHCS
along with the data of the dental FFS program to be posted on
the department's Internet Website commencing January 31, 2017,
for the 2015-16 fiscal year, and annually on or before January
31 each year thereafter.
14)Requires DHCS to post dental FFS performance data on a
quarterly basis commencing April 30, 2017 on their Internet
Website.
EXISTING LAW:
1)Requires DHCS to establish a list of performance measures
designed to evaluate utilization, access, availability, and
effectiveness of preventive care and treatment to ensure the
dental FFS program meets quality and access criteria created
by DHCS after consultation with key stakeholders as specified.
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2)Requires DHCS to prepare, on an annual basis, a summary report
of the nature and types of complaints and grievances regarding
access to, and quality of, dental services, including the
outcome and requires the report to be posted on their Internet
Website.
3)Requires DHCS to establish a list of performance measures to
ensure dental health plans meet quality criteria required by
DHCS including but not be limited to provider network
adequacy, overall utilization of dental services, annual
dental visits, use of preventive dental services, use of
dental treatment services, use of examinations and oral health
evaluations, and other measures as specified.
4)Requires the performance measures to specify the benchmarks
used by DHCS to determine whether and the extent to which a
dental health plan meets each performance measure. Requires
the Department of Managed Health Care (DMHC) and the DHCS
stakeholder advisory committee to have access to all
performance measures and benchmarks used by DHCS.
5)Requires that the survey of member satisfaction with plans and
providers be the same dental version of the Consumer
Assessment of Healthcare Providers and Systems (CAHPS) survey
as used by the previously established Healthy Families
Program.
6)Requires DHCS to notify dental health plans at least 30 days
prior to the implementation date of performance measures and
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requires DHCS to include the initial list of performance
measures and benchmarks in any dental health contracts entered
into between the department and a dental health plan.
7)Requires DHCS to update performance measures and benchmarks
and establish additional performance measures and benchmarks,
as specified.
8)Requires DHCS to, when evaluating performance measures and
benchmarks for retention on, addition to, or deletion from the
list, consider all of the following criteria:
a) Monthly, quarterly, annual, and multiyear DMC trended
data;
b) County and statewide Medi-Cal dental FFS performance and
quality ratings;
c) Other state and national dental program performance and
quality measures; and,
d) Other state and national performance ratings.
9)When establishing and updating the performance measures and
benchmarks, requires DHCS to consult the existing managed care
stakeholder advisory committee well as dental health plan
representatives and other stakeholders, including
representatives from counties, local dental societies,
nonprofit entities, legal aid entities, and other interested
parties.
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10)Requires, when evaluating a dental health plan's ability to
meet the criteria established through the performance measures
and benchmarks, DHCS to select specific performance measures
as the basis for establishing financial or other incentives or
disincentives, including, but not limited to, bonuses, payment
withholds, and adjustments to beneficiary assignment to plan
algorithms.
11)Requires DHCS to designate an external quality review
organization (EQRO) to conduct external quality reviews for
any dental health plan contracting with DHCS.
12)Requires dental health plans, at least annually, to arrange
for an external quality of care review with the EQRO
designated by DHCS that evaluates the dental health plan's
performance in meeting the performance measures, as specified.
Permits DMHC direct access to all external quality of care
review information upon request to DHCS.
13)Requires all marketing methods and activities to be used by
dental plans to be in compliance with state regulations and
requires each dental plan to submit its marketing plan to DHCS
for review and approval.
14)Requires each dental plan to submit its member services
procedures, beneficiary informational materials, and any
updates to those procedures or materials to DHCS for review
and approval. Requires DHCS to ensure that member services
procedures and beneficiary informational materials are clear
and provide timely and fair processes for accepting and acting
upon complaints, grievances, and disenrollment requests,
including procedures for appealing decisions regarding
coverage or benefits.
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15)Requires each dental plan to submit its provider compensation
agreements to DHCS for review and approval.
16)Requires DHCS to post to its Internet Website a copy of all
final reports completed by DMHC dental managed care plans.
FISCAL EFFECT: This bill has not yet been analyzed by a fiscal
committee.
COMMENTS:
1)PURPOSE OF THIS BILL. According to the author, dental care
consistently ranks with the public as the most important type
of health care after medical. The impact that good dental
hygiene and health has on people's self-esteem and quality of
life cannot be understated. Dentistry is about prevention in
order to avoid costly intervention at a later date; however,
our system for participation and enrollment does not currently
reflect that. Participation and entry to the program as a
participating provider should be easy with restrictions and
limiting parameters put in place only when a dentist's pattern
of behavior warrants such. The limited number of private
practitioners able to participate in the program is concerning
due to the geographic limitations this can create. There are
counties in California with just a couple of dentists
participating in the program and too often these are older
dentists who will be retiring soon, with no dentists able to
take their place.
The author states that the Denti-Cal system is so broken that
many dentists provide pro-bono care as opposed to taking
Denti-Cal because they both give back to their community and
society and manage it in a way that it is not financially
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devastating to their practices. The real loss in this system
rests with beneficiaries. A 2014 California State Auditor
report indicated that the insufficient number of dental
providers willing to participate in Denti-Cal, low
reimbursement rates, and a failure to adequately monitor the
program, led to limited access to care and low utilization
rates for Denti-Cal beneficiaries across the state. The Audit
found that almost half of eligible beneficiaries did not
receive dental care they were eligible for. Additionally, an
April 2016 Little Hoover Commission (LHC) Report indicated
that with dreadful reimbursement rates for dentists and slow,
outdated paper-based administrative and billing processes that
compare poorly with those of commercial insurers, Denti-Cal
has thoroughly alienated its partners in the dental
profession. Most California dentists want nothing to do with
Denti-Cal and consequently, more than 13 million people
eligible for coverage have limited or no access to dentists.
This is unacceptable, and we must take action to change the
system. While the provisions in this bill seem modest, they
are significant steps towards improving the Denti-Cal system.
The author concludes that this measure will streamline the
enrollment process for providers, ensure that provider
networks are up-to-date so that beneficiaries can more easily
access providers, improve coordination of care for
beneficiaries, and increase DHCS oversight of the Denti-Cal
program.
2)BACKGROUND.
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a) Denti-Cal. States are federally required to provide
dental benefits to children covered by Medicaid (Medi-Cal
in California) and the Children's Health Insurance Program.
Denti-Cal is the Medicaid program that provides
comprehensive dental care to pediatric and pregnant
Medi-Cal beneficiaries and limited emergency services to
adult beneficiaries. While Medicaid covers dental services
for all child enrollees as part of a comprehensive set of
benefits, referred to as the Early and Periodic Screening,
Diagnostic and Treatment benefit, states may choose whether
to provide dental benefits for adults. Minimum federal
requirements for pediatric dental Medicaid programs include
relief of pain and infections, restoration of teeth and
maintenance of dental health. For children in Medi-Cal,
dental care is provided on a FFS basis in all counties,
with Sacramento and Los Angeles Counties also offering
services through DMC plans.
For more than 40 years Medicaid-enrolled Californians of
any age were eligible for basic diagnostic, preventive,
restorative and emergency dental procedures provided by
participating dentists through Denti-Cal. In 2007,
Denti-Cal provided comprehensive oral health care to more
than eight million people. However, from July 2009 to May
2014, California eliminated funding for most adult
non-emergency Denti-Cal benefits, effectively eliminating
California's oral health safety-net. A partial restoration
of benefits, primarily diagnostic and preventative
services, was enacted in the 2013 Budget Act and became
effective May 1, 2014.
b) Denti-Cal FFS Performance. In 2012, dental health plans
contracted with Barbara Aved Associates to conduct research
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on Medi-Cal's FFS dental care. The study found, in part,
that: i) 97% of non-participating dentists cited low
reimbursement rates as the reason for not participating;
ii) 90% of general dentists said it was somewhat or very
difficult to find a pediatric dentists accepting Medi-Cal
referrals; and, iii) 38% of general dentists and 69% of
pediatric dentists who take Medi-Cal have 15% or less of
their patient population in Medi-Cal. The researcher
concluded that children in Medi-Cal are getting inadequate
dental care, largely due to insufficient provider
participation, reflecting low reimbursement rates. The
researcher recommended: i) streamlining the provider
enrollment process; ii) increasing rates; iii) adopting
more quality measures; iv) increasing monitoring of
utilization data; and, v) increasing public oral health
education to families
c) Denti-Cal Managed Care Performance. Under the FFS
model, providers are reimbursed according to a rate
schedule set by DHCS. The Medi-Cal Dental Managed Care
Program contracts with three Geographic Managed Care (GMC)
Plans and five Prepaid Health Plans that provide dental
services to enrolled beneficiaries. Each dental plan
receives a negotiated monthly per capita rate from the
state for every recipient enrolled in their plan. Medi-Cal
beneficiaries residing in Los Angeles County can access
dental care either through the FFS delivery system or
through prepaid health plans, while Medi-Cal beneficiaries
residing in Sacramento County (with the exception of
specific populations) are mandatorily enrolled in prepaid
health plans for dental care. If Sacramento County
beneficiaries are unable to secure services through their
prepaid health plan in accordance with the applicable
contractual time frames and the Knox-Keene Health Care
Service Plan Act of 1975, they can qualify for the
beneficiary dental exemption, which allows them to move
into the FFS delivery system. In 2012, about 143,000 child
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beneficiaries received services under the DMC plans
operating in the counties of Los Angeles and Sacramento.
In 2010, First 5 of Sacramento commissioned the "Sacramento
Deserves Better" report, produced by Barbara Aved
Associates, which analyzed access, utilization, and quality
of dental care under Sacramento's GMC Dental Services
model. Key findings from this report include the
following:
i) Only 20% of children in GMC dental services used a
dental service in 2008, as compared to over 40% of
children in Medi-Cal statewide who are predominately in
FFS;
ii) Only 30% of children in GMC dental services received
a dental service in 2010;
iii) Sacramento GMC dental services is consistently one
of the lowest-ranking counties for Medi-Cal dental access
in the entire state;
iv) Dental plans have not complied with a "first
tooth/first birthday" recommendation for the initial
dental visit;
v) Inadequate prevention services were provided; and,
vi) The state provided minimal oversight of GMC dental
services contracts.
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Early in 2012, through a series of articles and editorials,
the Sacramento Bee (Bee) brought attention to the dire
conditions of Sacramento County's pediatric DMC program.
The Bee coverage focused on the findings of the report
commissioned by First 5 of Sacramento, which revealed
shockingly low utilization rates and highlighted a series
of examples of specific children who had been in desperate
need of dental care, yet unable to access the care they
needed without significant delays, worsening conditions,
prolonged pain, and a significant amount of fear,
frustration, and relentless advocacy on the part of their
parents.
d) Legislative Hearings. A series of legislative hearings
in 2012 found a lack of oversight of the DMC programs in
Sacramento and Los Angeles counties by DHCS, resulting in
significant underutilization by pediatric beneficiaries. On
March 8, 2012, the Assembly Select Committee on Workforce
and Access to Care convened a meeting to examine the state
of the dental safety net, followed by a Senate Budget
Hearing on March 22, 2012, that directly examined the
Sacramento GMC dental program. As a result, 2012 budget
trailer bill provided for the beneficiary dental exemption
process, which allows beneficiaries who are not receiving
adequate or timely access to care to opt out of the GMC
dental program, requires DHCS to establish performance
measures and benchmarks for dental health plans, requires
DHCS to utilize dental health plan performance data for
contracting purposes, and requires the establishment of
contract incentives and disincentives, along with enacting
other oversight mechanisms.
e) Office of Inspector General Report. In January 2016, the
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federal Department of Health and Human Services Officer of
the Inspector General (OIG) published a report titled "Most
Children with Medicaid in Four States are Not Receiving
Required Dental Services." The study focused on four
states: California, Indiana, Louisiana, and Maryland and
analyzed Medicaid dental claims with service dates in 2011
and 2012, beneficiary enrollment files, and conducted
structured interviews with state officials. The OIG report
found that three out of four children did not receive all
required dental services, with one in four children failing
to see a dentist at all. All four states reported that
they do not routinely track whether children are receiving
all the required services. In addition, two of the four
states had policies that do not allow payment for
particular services in accordance with their periodicity
schedules. All states reviewed reported facing shortages
of participating dental providers and challenges in
educating families about the importance of regular dental
care.
f) State Auditor's Report. On December 11, 2014, the
California State Auditor issued a report titled "California
Department of Health Care Services: Weaknesses in Its
Denti-Cal Limit Children's Access to Dental Care." The
report stated that insufficient number of dental providers
willing to participate in Medi-Cal, low reimbursement rates
and a failure to adequately monitor the program, led to
limited access to care and low utilization rates for
Medi-Cal beneficiaries across the state. The Audit found
that 16 counties either have no active providers or do not
have providers willing to accept new Medi-Cal patients, and
16 other counties have an insufficient number of providers.
Recent changes in federal and state laws that have
expanded Medi-Cal coverage could increase the number of
children and adults who can receive additional covered
dental services from 2.7 million to as many as 6.4 million,
bringing into question the state's ability to provide
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timely and adequate care to beneficiaries.
g) LHC Report. On April 1, 2016, the LHC published a
report titled "Fixing Denti-Cal." The LHC initiated an
examination of the state's Denti-Cal program after
receiving formal requests for a review from Legislators in
April of 2015 and following the findings of the 2014 State
Auditor's Report. Lawmakers requested that the LHC
"undertake a review of the Denti-Cal program and identify
the necessary steps to assure this vital program meets its
purpose to provide access to dental care for many of the
most vulnerable Californians including children." The LHC
Report highlighted the lack of providers in the Denti-Cal
program, inadequate and low provider reimbursement rates,
enrollment, billing, and administrative challenges. The
LHC provided 11 recommendations on how to improve the
Denti-Cal program, as follows:
i) The Legislature should set a target of 66% of
children with Denti-Cal coverage making annual dental
visits;
ii) DHCS should simplify the Denti-cal provider
enrollment forms and put them online in 2017;
iii) DHCS should overhaul the process of treatment
authorization requests;
iv) DHCS should implement a customer focused program
to improve relationships with its providers;
v) DHCS should purge outdated regulations;
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vi) The Legislature and Governor should enact and
sign legislation in 2016 to create an evidence-based
advisory group for the Denti-Cal program;
vii) The Legislature and Governor should fund a
statewide expansion of teledentistry and the virtual
dental home;
viii) State government, funders, and non-profits
should lead a sustained statewide "game changer" to
reorient the oral health care system for Denti-Cal
beneficiaries toward preventative care;
ix) The Legislature and DHCS should expand the
concepts of Washington State's Access to Baby and Child
Dentistry program and Alameda County's Healthy Kids,
Healthy Teeth program to more regions of California;
x) DHCS and California counties should steer more
Denti-Cal eligible patients into Federally Qualified
Health Centers with capacity to see them; and,
xi) Medical societies and non-profit organizations
should recruit more pediatricians to provide
preventative dental checkups during well-child visits.
h) Transformation Waiver. The new "Medi-Cal 20-20 Waiver"
includes provisions to implement the "Dental Transformation
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Initiative" (DTI), which aims to improve dental health for
Medi-Cal children by focusing on high-value care, improved
access, and utilization of performance measures to drive
delivery system reform. The DTI provides incentive
payments to Medi-Cal dental providers who meet certain
requirements and benchmarks. The DTI provides $148 million
annually in funding for five years for a maximum of $750
million. More specifically, DTI will include three
domains: preventive service, caries risk assessment and
management, and continuity of care. Specific incentive
payments within each domain will be available to qualified
providers, along with messaging and education to providers
and beneficiaries about programs and efforts in their local
communities.
3)SUPPORT. The LHC states that in its 2016 report, Fixing
Denti-Cal, the LHC found the program to be lacking in multiple
areas. The LHC made several recommendations aimed at
expanding access to Denti-Cal services, with an ultimate goal
of 66% of Denti-Cal-eligible children making annual dental
visits. Several of those recommendations would require DHCS
to take action to improve Denti-Cal from within. This bill
would call on DHCS to expedite provider enrollment by creating
a dental-specific enrollment form and pursuing alternative
automatic enrollment for dentists already established
commercially. This bill would also require DHCS to monitor
access and utilization and explore additional opportunities to
improve Denti-Cal. The LHC concludes that because this bill
requires DHCS to improve and expand Denti-Cal provider
enrollment, and shares the LHC's overall goal of expanding
access to care, it supports this measure.
The County Health Executives Association of California state
that this bill proposes modest changes to the program,
including expediting dental provider enrollment into the
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Medi-Cal program, ensuring screenings are provided for every
eligible Medi-Cal beneficiary as part of their initial health
assessment, and ensuring beneficiaries are referred to
appropriate Medi-Cal dental providers, which could improve the
delivery of dental services to those most in need in
California.
4)SUPPORT IF AMENDED. The Maternal and Child Health Access
strongly supports the provisions of this bill, but urge
amendments to clarify the intent that all pregnant women in
Medi-Cal benefit from this bill's reforms, add performance
measures unique to pregnant and postpartum beneficiaries,
include maternal and infant health advocates in the
stakeholder group and require DHCS to report access, and
quality data for pregnant beneficiaries.
Western Center on Law and Poverty also supports this bill, and
urge amendments that add quality performance measures for
adults, require the Denti-Cal provider referral list to be
updated, and review ways to stream the Treatment Authorization
Requests process.
5)RELATED LEGISLATION.
a) AB 648 (Low) establishes the Virtual Dental Home program
to expand the virtual dental home model of community-based
delivery of dental care and directs the California Health
Facilities Financing Authority to administer the grant
program. AB 648 is on the Senate Inactive File.
b) AB 2108 (Waldron) requires DHCS, on or before January 1,
2018, to submit a report to the Legislature on the cost and
feasibility of restoring full adult dental services as a
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covered benefit under the Medi-Cal Program and sunsets
those provisions on January 1, 2019. AB 2108 is pending in
the Assembly Health Committee.
6)PREVIOUS LEGISLATION. AB 1467 (Committee on Budget), Chapter
23, Statutes of 2012, allows Sacramento County to establish a
stakeholder advisory committee (SC-SAC) to provide input on
the delivery of oral health and dental care and required DHCS
and the Sacramento County Department of Health and Human
Services advisory committee to meet with the SC-SAC.
Authorizes the Director of DHCS to establish a beneficiary
dental exception process in which Medi-Cal beneficiaries who
are mandatorily enrolled in dental health plans in Sacramento
County can move to FFS Denti-Cal. Requires DHCS to establish
a list of performance measures to ensure that dental health
plans meet quality criteria and required DHCS to post on its
Website on a quarterly basis, beginning January 1, 2013, the
list of performance measures and each plan's performance and
made other changes to DMC as specified.
7)COMMITTEE AMENDMENTS.
a) Disenrollment process clarification. The Committee
recommends an amendment clarifying that if 12 months have
passed since an enrolled Denti-Cal provider has made a
claim for services rendered to a Denti-Cal beneficiary, a
notice should be provided to that provider informing them
that within 6 months they will be disenrolled from the
Denti-Cal program.
b) Distribution of providers and services. The author
wishes to amend the bill to add to the list of performance
measures established by DHCS data regarding the number of
patients seen by a Dent-Cal provider in one calendar year,
and the number of services rendered by that provider.
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REGISTERED SUPPORT / OPPOSITION:
Support
California Dental Association
Children Now
California Primary Care Association
Children's Partnership
County Health Executives Association of California
First 5 Association of California
National Association of Social Workers - California Chapter
The Little Hoover Commission
Opposition
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None on file.
Analysis Prepared by:Paula Villescaz / HEALTH / (916) 319-2097