BILL ANALYSIS                                                                                                                                                                                                    ”



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          ASSEMBLY THIRD READING


          AB  
          2207 (Wood)


          As Amended  April 26, 2016


          Majority vote


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          |Committee       |Votes|Ayes                  |Noes                |
          |                |     |                      |                    |
          |                |     |                      |                    |
          |                |     |                      |                    |
          |----------------+-----+----------------------+--------------------|
          |Health          |16-0 |Wood, Maienschein,    |                    |
          |                |     |Bonilla, Campos,      |                    |
          |                |     |Chiu, Dababneh,       |                    |
          |                |     |Gomez, Roger          |                    |
          |                |     |HernŠndez, Lackey,    |                    |
          |                |     |Nazarian, Olsen,      |                    |
          |                |     |Patterson, Rodriguez, |                    |
          |                |     |Santiago, Steinorth,  |                    |
          |                |     |Waldron               |                    |
          |                |     |                      |                    |
          |----------------+-----+----------------------+--------------------|
          |Appropriations  |20-0 |Gonzalez, Bigelow,    |                    |
          |                |     |Bloom, Bonilla,       |                    |
          |                |     |Bonta, Calderon,      |                    |
          |                |     |Chang, Daly, Eggman,  |                    |
          |                |     |Gallagher, Eduardo    |                    |
          |                |     |Garcia, Roger         |                    |
          |                |     |HernŠndez, Holden,    |                    |
          |                |     |Jones, Obernolte,     |                    |
          |                |     |Quirk, Santiago,      |                    |








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          |                |     |Wagner, Weber, Wood   |                    |
          |                |     |                      |                    |
          |                |     |                      |                    |
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          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 by creating a dental-specific enrollment form,  
            pursuing an alternative automatic enrollment process for a  
            provider already commercially credentialed, and other  
            activities, as specified;


          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  








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            consultation with stakeholders, to improve the Denti-Cal, as  
            specified;


          5)Allows DHCS to implement, interpret, or make specific policies  
            and procedures by means of all-county letters, plan letters,  
            plan or provider bulletins, or similar instructions, requires  
            DHCS to thereafter adopt regulations, and requires DHCS to  
            update the legislature until regulations are adopted. 


          6)Makes implementation of most of its provisions contingent upon  
            federal approval, availability of federal matching funds, and  
            an appropriation in the annual Budget Act each fiscal year for  
            the specific purpose of implementation.


          7)Contains other provisions to improve Denti-Cal accountability,  
            transparency, and quality. 


          FISCAL EFFECT:  According to the Assembly Appropriations  
          Committee:


          1)DHCS states most activities required by this bill are simply  
            aligning statute with their current contracts or current  
            activities to improve Denti-Cal, and that this bill does not  
            result in a direct staff cost increase.  Despite this, the  
            bill makes implementation of the bill's major provisions  
            contingent on an appropriation for the specific purpose of its  
            implementation.


          2)This bill also contains a provision that could result in  
            ongoing state cost pressure, namely the requirement that DHCS  
            assess opportunities to improve access and utilization.   
            Improving access and boosting utilization, however  
            appropriate, is likely to have unknown, significant, ongoing  








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            costs for increased Denti-Cal services, likely offset to some  
            extent by a reduction in costs to treat more serious dental  
            disease (General Fund (GF)/federal funds).  


          3)This bill also requires DHCS to assess opportunities to  
            implement innovative payment reform proposals, which are  
            unlikely to result in a net ongoing cost increase, but could  
            result in significant one-time development and implementation  
            costs (GF/federal funds). 


          COMMENTS:  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  
          devastating to their practices.  The real loss in this system  
          rests with beneficiaries.  










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          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. 


          Office of Inspector General Report.  In January 2016, the  
          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  








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          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. 


          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 timely and adequate care  
          to beneficiaries.


          Little Hoover Commission (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  








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          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.  




          Analysis Prepared by:                                             
                          Paula Villescaz / HEALTH / (916) 319-2097  FN:  
          0003288