BILL ANALYSIS Ó
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: AB 2207
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|AUTHOR: |Wood |
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|VERSION: |June 9, 2016 |
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|HEARING DATE: |June 22, 2016 | | |
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|CONSULTANT: |Scott Bain |
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SUBJECT : Medi-Cal: dental program
SUMMARY : Requires the Department of Health Care Services (DHCS) to
expedite the Medi-Cal dental program (Denti-Cal) provider
enrollment process, including an alternative automatic
enrollment process for a provider already commercially enrolled,
subject to federal approval. Requires automatic disenrollment of
a dental provider who has not submitted a claim over a
continuous 12-month period, after notice to the provider.
Requires DHCS to monitor access and utilization of Denti-Cal
services to assess opportunities to improve access and
utilization. Expands and aligns Denti-Cal fee-for-service and
Denti-Cal managed care annual reporting requirements, and
requires quarterly data reporting requirements. Codifies the
data reporting and evaluation requirements for the Dental
Transformation Initiative in the state's "Medi-Cal 2020" Section
1115 waiver.
Existing law:
1)Establishes the Medi-Cal program, which is administered by
DHCS, under which qualified low-income individuals receive
health care services, including certain dental services, as
specified. Dental services are delivered through the
fee-for-service (FFS) Denti-Cal program, except in Sacramento
County, where enrollment in a dental managed care plan is
required (with exceptions), and in Los Angeles County, where
beneficiaries have the option to enroll in a dental managed
care plan.
2)Requires DHCS to establish a list of performance measures to
ensure the FFS Denti-Cal program meets quality and access
criteria required by DHCS. Requires the performance measures
to be designed to evaluate utilization, access, availability,
and effectiveness of preventive care and treatment.
AB 2207 (Wood) Page 2 of ?
3)Requires DHCS to establish measures to monitor the dental FFS
Denti-Cal program, and requires specific performance measures
for children, and a more limited set of performance measures
for adults.
4)Requires DHCS to establish a list of performance measures to
ensure Denti-Cal dental health plans meet quality criteria
required by DHCS. Requires the list to specify the benchmarks
used by DHCS to determine whether and the extent to which a
dental health plan meets each performance measure.
This bill:
1)Requires the FFS Denti-Cal performance measures for adults and
children to include the total number of patients seen, on a
per-provider basis, and the total number of preventive dental
services, dental treatment services, and examinations and oral
health evaluations rendered by each provider during each
calendar year.
2)Requires quarterly (instead of annual) posting of the data of
the Denti-Cal dental FFS and managed care program performance
measures to be posted on DHCS' Internet Web site, beginning
April 1, 2017. Aligns the timing of the Denti-Cal FFS and
managed care reports.
3)Requires DHCS to ensure, to the greatest degree possible, that
the categories of data and performance measures selected for
Denti-Cal FFS are consistent with the categories of data and
performance measures selected for Denti-Cal managed care
plans.
4)Requires DHCS to expedite the enrollment of Medi-Cal dental
providers by streamlining the Medi-Cal provider enrollment
process. Requires DHCS to pursue and implement all of the
following activities, to the extent permitted by federal law:
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 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
AB 2207 (Wood) Page 3 of ?
application packet; and,
d) To publish the criteria for those processes in
applicable provider bulletins and manuals, to the extent
that DHCS expedites the enrollment of Medi-Cal dental
providers by streamlining the Medi-Cal provider
enrollment process.
5)Requires DHCS to maintain the provider network by disenrolling
a billing and rendering provider who has not, over a
continuous 12-month period, submitted a claim for
reimbursement for services rendered.
6)Requires DHCS, prior to disenrolling a provider, to send a
notice to the provider that the provider will be disenrolled
from the dental program six months after the date of the
notice. Prohibits DHCS from disenrolling a provider until six
months after the date of that notice.
7)Requires DHCS, in order to improve the quality of the dental
provider network, to also exercise additional measures as
appropriate and permitted by law, including, but not limited
to, temporary suspensions. Requires the parameters and
criteria developed by DHCS for additional measures for
disenrollments to be published in applicable provider
bulletins and manuals.
8)Requires DHCS to monitor access and utilization of Medi-Cal
dental services in the FFS and managed care delivery systems
to assess opportunities to improve access and utilization.
9)Requires DHCS to assess opportunities to develop and implement
innovative payment reform proposals within the Medi-Cal dental
programs.
10)Requires DHCS to explore additional opportunities to improve
the Medi-Cal Dental Program, in consultation with stakeholders
and as deemed appropriate by the DHCS and to the extent
permitted by federal law, including, but not limited to, the
following:
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
AB 2207 (Wood) Page 4 of ?
to care while still protecting program integrity; and,
c) Expanding the scope of beneficiary outreach
activities required by an entity that is contracted
with DHCS to more broadly address underutilization
throughout the state.
1)Requires DHCS, prior to implementing an action pursuant to 10)
above, to post the proposed action on its Internet Web site at
least 30 days before implementation.
2)Requires DHCS to work with Denti-Cal managed care plans that
contract with DHCS to provide beneficiaries with access to
dental plan liaisons to assist in the coordination of care for
enrolled members.
3)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 appropriate Medi-Cal dental provider; and,
c) Identify plan liaisons available to dental
managed care contractors and dental FFS contractors to
assist with referrals to health plan covered services
that may be needed by the beneficiary to aid in the
treatment of an identified oral health care condition.
1)Exempts any contract amendment, modification, or change order
to any contract entered into by DHCS for the purpose of
implementing the state Medi-Cal Dental Program from specified
provisions of the Public Contract and Government Codes, in
addition to any policies, procedures, or regulations
authorized by those provisions. Prohibits this provision from
exempting DHCS from establishing a competitive bid process for
awarding new fiscal intermediary contracts, as well as for
awarding new Denti-Cal managed care contracts.
2)Requires DHCS, prior to implementing any change under this
bill, to consult with, and provide notification to,
stakeholders, including representatives from counties, local
dental societies, nonprofit entities, legal aid entities, and
other interested parties.
3)Requires DHCS to implement, interpret, or make specific
AB 2207 (Wood) Page 5 of ?
policies and procedures pertaining to the dental FFS program
and dental managed care plans, as well as applicable federal
waivers and state plan amendments, including the provisions
set forth in this bill, by means of all-county letters, plan
letters, plan or provider bulletins, or similar instructions
without taking regulatory action, until regulations are
adopted.
4)Requires DHCS, no later than December 31, 2018, to adopt
regulations in accordance with the Administrative Procedures
Act. Requires DHCS to provide a status report to the
Legislature on a semiannual basis until regulations have been
adopted beginning six months after the effective date of this
bill.
5)Implements this bill only to the extent that DHCS obtains any
federal approvals necessary to implement this bill and obtains
federal matching funds to the extent permitted by federal law.
6)Codifies the Dental Transformation Initiative (DTI) data
reporting and evaluation quality measure requirements required
to be reported to the federal government and made publicly
available for each of the four DTI domains contained in the
Special Terms and Conditions (STCs) of Medi-Cal 2020, the
state's Section 1115 Medicaid waiver.
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
costs for increased Denti-Cal services, likely offset to some
extent by a reduction in costs to treat more serious dental
disease (GF/federal).
AB 2207 (Wood) Page 6 of ?
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).
PRIOR
VOTES :
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|Assembly Floor: |80 - 0 |
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|Assembly Appropriations Committee: |20 - 0 |
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|Assembly Health Committee: |16 - 0 |
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COMMENTS :
1)Author's statement. 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,
California's system for participation and enrollment does not
currently reflect 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. 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
AB 2207 (Wood) Page 7 of ?
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 program.
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 increases DHCS
oversight of the Denti-Cal program.
2)Medi-Cal has two different models for delivering dental
services. The Medi-Cal Program is administered by DHCS and
covers dental services for children under age 21 and a more
limited benefit for adults. Adult dental coverage was
eliminated in 2009 in AB 5 (Committee on Budget, Chapter 20,
Statutes of 2009), which also eliminated other optional
benefits for adults that had been covered under Medi-Cal. A
more limited adult dental benefit was restored in AB 82
(Budget Committee, Chapter 23, Statutes of 2013), the 2013-14
budget health trailer bill.
Medi-Cal uses two different models for delivering dental
services to children: FFS and Dental Managed Care:
a) FFS. In the FFS dental model, beneficiaries may
receive dental services from any provider who accepts
Medi-Cal payments and agrees to see them. Dental
providers receive a payment for each service provided
to the Medi-Cal beneficiary. FFS Denti-Cal expenditures
are projected to be $1.05 billion total funds ($357.6
million GF) in 2016-17; and,
b) Denti-Cal managed care. In the dental managed
care model, Medi-Cal pays dental plans a set amount per
member per month (also known as a capitation rate) to
provide dental care to beneficiaries enrolled in the
plan. For most eligibles, the monthly per person rate
is between $7.80 and $13.50 (monthly capitation rates
are different for adults and children and refugees) for
every Medi-Cal beneficiary enrolled in their plan.
Generally, enrollees may only receive services from
providers that are within the plan's provider network.
AB 2207 (Wood) Page 8 of ?
Only two counties have dental managed care. In
Sacramento, almost all children and adults are
mandatorily enrolled in a dental managed care plan. If
a beneficiary does choose a dental managed care plan,
the beneficiary will be automatically assigned to one.
In Los Angeles County, beneficiaries may voluntarily
enroll in a dental managed care plan. If a beneficiary
in Los Angeles County does not choose to enroll in a
dental managed care plan, they are automatically
enrolled in FFS. Denti-Cal managed care expenditures
are projected to be $166.8 million total funds ($65.7
million GF).
Denti-Cal utilization is low, with different estimates for
different time frames. According to the Little Hoover
Commission report, only 26% of eligible California adults
with FFS Denti-Cal coverage saw a dentist in 2014,
according to February 2016 DHCS data. DHCS stated that
51.8% of children 20 and under with Denti-Cal FFS coverage
had a dental visit from October 2014 through September
2015. In December 2015, the Centers for Medicare and
Medicaid Services (CMS), in approving the California
Medi-Cal 2020 waiver, cited a figure of 37.8% of children
20 and under making a dental visit during the calendar year
2014. In December 2014, the California State Auditor cited
CMS data to report that only 44% of California's 5.1
million Denti-Cal-eligible children aged 20 and under saw a
dentist from October 2012 through September 2013.
DHCS currently has a small workgroup effort regarding
implementation of the Dental Transformation Initiative
under the Medi-Cal 2020 Waiver. The purpose of this
workgroup is to collaborate with DHCS on the planning and
implementation efforts that are needed to ensure the
success of the dental component of the waiver.
1)Dental provider enrollment. This bill requires DHCS to
expedite the enrollment of Medi-Cal dental providers by
streamlining the Medi-Cal provider enrollment process. To the
extent allowed by federal law, DHCS would be required to:
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
AB 2207 (Wood) Page 9 of ?
as a commercial provider, and to
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.
DHCS indicates Denti-Cal providers do not get enrolled through
the Medi-Cal Provider Enrollment Division. Instead, dental
providers use a paper application similar to the FFS Medi-Cal
provider application, which DHCS indicates is very thorough
and requires extensive review. Delta Dental handles Denti-Cal
enrollment, and DHCS indicates the review is equally as
thorough as the medical enrollment process. Prior to the
introduction of this bill, Denti-Cal was evaluating the
creation of a dental specific application because medical
providers were moving toward on-line enrollment through PAVE,
and many concerns had been raised to DHCS that the application
questions may not pertain to dentists. In addition, because
Delta Dental currently operates commercial dental coverage, it
has can verify credentials and identify the dentists that
serve in the commercial side who are also seeking Denti-Cal
enrollment. DHCS indicates it has developed a revised paper
application that will be going out shortly for stakeholder
review, which will serve as an interim step before moving
towards the use of PAVE for dental providers.
1)Denti-Cal rates. On July 1, 2016, DHCS released its
statutorily required "Medi-Cal Dental Services Rate Review" in
which it compared the reimbursement rates of Denti-Cal FFS' 25
most utilized procedures to the same 25 procedure codes from
other states' Medicaid dental fee schedules. These 25
procedures made up approximately 85% of billed procedures in
FY 2012-13 and FY 2013-14. California's Denti-Cal FFS pays an
average of 86.1% of Florida's Medicaid Program's dental fee
schedule, 65.5% of Texas', 75.4% of New York's, and 129.2% of
Illinois' Medicaid Program's dental fee index. The report
found that Denti-Cal paid, on average, 28.3% of commercial
rates in the Pacific Area in 2013-14.
2)Dental Transformation Initiative of Medi-Cal Section 1115
Waiver. The DTI is a new feature of Medi-Cal 2020, the state's
most recent Section 1115 waiver. It is funded at $750 million
total funds ($375 million in federal funds) generated from
federal waiver funding drawn down for Designated State Health
Programs. Of this amount, $10 million in total funds is
contingent upon the state meeting statewide metrics. AB 1568
AB 2207 (Wood) Page 10 of ?
(Bonta and Atkins) would codify the DTI provisions of the
Special Terms and Conditions of the waiver. DTI consists of
four domain areas as follows:
a) Domain 1: Increase Preventive Services Utilization for
Children;
b) Domain 2: Caries Risk Assessment and Disease Management;
c) Domain 3: Increase Continuity of Care; and,
d) Domain 4: Local Dental Pilot Programs.
This bill would codify the STCs provisions regarding DHCS
reporting DTI data and quality measures. Under the STCs, this
information is required to be sent to the federal Centers for
Medicare and Medicaid Services and made publicly available.
1)Related legislation.
a) SB 1098 (Cannella) establishes in DHCS the 13-member
Denti-Cal Advisory Group (Advisory Group), and specifies
the duties of the advisory group to include studying the
policies and priorities of Denti-Cal with the goal of
raising the Denti-Cal utilization rate among eligible
child beneficiaries to 60% or greater and providing
assistance and advice to DHCS, the Legislature, and the
Governor regarding proposed decisions relating to the
Denti-Cal program to ensure that those decisions are
based on the best available evidence. SB 1098 is in the
Assembly Health Committee.
b) AB 1051 (Maienschein) appropriates $200 million from
the GF to DHCS for the Denti-Cal program. DHCS would be
required to allocate the funds to increase reimbursement
rates for the 15 most common prevention, treatment, and
oral evaluation services to the Medicaid national
average, and to increase funding for preventative care
and case management services, as appropriate, to achieve
significant long-term cost savings, increased provider
participation, and increased beneficiary utilization
under Denti-Cal. AB 1051 is in the Senate Health
Committee and is scheduled for hearing on June 29, 2016.
c) AB 1586 (Bonta and Atkins) and SB 815 (Hernandez and
De Leon) are companion urgency bills to enact specified
statutory provisions of "Medi-Cal 2020," the state's
recently approved five-year federal Section 1115 waiver,
AB 2207 (Wood) Page 11 of ?
which runs through December 31, 2020. AB 1586 includes
the DTI, the Whole Person Care program and the
evaluations required under the Special Terms of
Conditions (STCs) of Medi-Cal 2020, and requires DHCS to
conduct or arrange to have conducted studies, reports and
assessments required under the STCs. SB 815 (Hernandez
and De Leon) contains the provisions implementing the
Global Payment Program and the Public Hospital Redesign
Incentive Program and the access assessment requirements.
SB 815 passed out of the Assembly Appropriations
Committee on June 15, 2016 and AB 1568 is scheduled to be
heard in the Senate Appropriations Committee on June 20,
2016.
1)Prior legislation. SB 694 (Padilla of 2011-12), would have
established the Statewide Office of Oral Health (Office)
within the Department of Public Health and authorized the
Office to conduct a study to assess the safety, quality,
cost-effectiveness, and patient satisfaction of expanded
dental procedures performed by specified dental health care
providers. SB 694 was held on the Assembly Appropriations
Committee suspense file.
AB 82 (Committee on Budget, Chapter 23, Statutes of 2013),
restored partial adult optional dental benefits, including
full mouth dentures, effective May 1, 2014. The fiscal impact
of the restoration is $183.8 million for 2015-16 and $339.9
million for 2016-17.
SB 75 (Committee on Budget and Fiscal Review, Chapter 18,
Statutes of 2015), the health budget trailer bill of 2015,
exempted FFS and dental managed care dental services and
applicable ancillary services for dates of service on or after
July 1, 2015, or the effective date of any necessary federal
approvals, whichever is later from the 10% Denti-Cal rate
reduction. The total funds cost for this change is $105
million.
2)Support. The Little Hoover Commission (LHC), in its 2016
report, Fixing Denti-Cal, 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 administrative actions to improve Denti-Cal. This bill
AB 2207 (Wood) Page 12 of ?
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 indicates it supports this bill
because it requires DHCS to improve and expand Denti-Cal
provider enrollment, and shares the LHC's overall goal of
expanding access to care.
The County Health Executives Association of California state
that this bill proposes modest changes to the program,
including expediting dental provider enrollment into the
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.
3)Proposed author's amendments. The author is proposing
amendments to address concerns amendments requested by several
stakeholder groups. These changes include three changes
requested by Western Center on Law and Poverty to broaden the
Denti-Cal performance measures for adults to align those
measures with the measures for children, to require DHCS to
"continuously" maintain the Denti-Cal provider network, and to
include an annual review of the Denti-Cal Treatment
Authorization Review process as part of DHCS' requirement
under this bill to monitor access and utilization. In
addition, the author's proposed amendments include a request
by health plans to clarify the scope of the requirement in
this bill that Medi-Cal managed care plans identify plan
liaisons available to dental managed care and FFS contractors.
This amendment would delete language in the requiring health
plans to assist with referrals "that may be needed by the
beneficiary to aid in the treatment of an identified oral
health care condition." Finally, the author is proposing
amendments to add the number of applications of fluoride
varnishes and the number of beneficiaries requiring general
anesthesia to the list of Denti-Cal performance measures.
10)Clarifying amendments. To clarify the Denti-Cal FFS child and
adult performance measure monitoring requirements changes made
by this bill, staff recommends these provisions be re-worded
to clarify which provisions are required to be reported in
AB 2207 (Wood) Page 13 of ?
aggregate versus on a per dental provider basis.
SUPPORT AND OPPOSITION :
Support: California Coverage and Health Initiatives
California Dental Association
California Pan-Ethnic Health Network
California Primary Care Association
Children Now
Children's Defense Fund-California
Children's Partnership
County Health Executives Association of California
First 5 Association of California
National Association of Social Workers, California
Chapter
Nurse-Family Partnership
The Little Hoover Commission
Oppose: None received
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