BILL ANALYSIS Ó
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|SENATE RULES COMMITTEE | AB 2207|
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THIRD READING
Bill No: AB 2207
Author: Wood (D)
Amended: 8/15/16 in Senate
Vote: 21
SENATE HEALTH COMMITTEE: 9-0, 6/22/16
AYES: Hernandez, Nguyen, Hall, Mitchell, Monning, Nielsen,
Pan, Roth, Wolk
SENATE APPROPRIATIONS COMMITTEE: 7-0, 8/11/16
AYES: Lara, Bates, Beall, Hill, McGuire, Mendoza, Nielsen
ASSEMBLY FLOOR: 80-0, 5/31/16 - See last page for vote
SUBJECT: Medi-Cal: dental program
SOURCE: Author
DIGEST: This bill 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 deactivation 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.
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ANALYSIS:
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.
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 specified measures, including number
of applications of fluoride varnishes, and number of
beneficiaries requiring general anesthesia to perform
procedures.
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2) Requires, no sooner than July 1, 2019, DHCS to annually
publish and post on its Internet Web site utilization data
from the preceding calendar year for FFS and managed care on
specified utilization measures.
3) 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.
4) 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.
5) 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
application packet; and,
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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.
6) Requires DHCS to maintain the provider network on a monthly
basis by deactivating a billing provider who has not, over a
continuous 12-month period, submitted a claim for
reimbursement for services rendered.
7) Requires DHCS, prior to deactivating a provider, to send a
notice to the provider that the provider will be deactivated
from the dental program six months after the date of the
notice. Prohibits DHCS from deactivating a provider until six
months after the date of that notice.
8) 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.
9) 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,
including an annual review of the treatment authorization
process.
10)Requires DHCS to assess opportunities to develop and
implement innovative payment reform proposals within the
Medi-Cal dental programs.
11)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
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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 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,
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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
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
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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.
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
the dental profession. Most California dentists want nothing
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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 bill 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.
FISCAL EFFECT: Appropriation: No Fiscal
Com.:YesLocal: No
According to the Senate Appropriations Committee:
1)One-time costs of $370,000 and ongoing costs of $340,000 per
year for additional collection, analysis, and reporting of new
performance measures by DHCS (General Fund/GF and federal
funds).
2)Unknown costs to make administrative changes to the system for
enrolling Denti-Cal providers (GF and federal funds). The bill
requires DHCS to make several changes to the processes and
systems for enrolling dental providers into the program, such
as requiring the use of a dental-specific enrollment form,
pursuing an automatic enrollment process for
commercially-credentialed providers, and improving the system
for maintaining the provider network. DHCS has already began
some of these processes, such as simplifying the paper
enrollment application. Other activities, such as
automatically enrolling commercially-credentialed providers
have not begun and will impose unknown administrative costs to
implement. On the other hand, improvements to the system for
provider enrollment may reduce future administrative workload
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to process enrollment applications, which are currently very
labor intensive to DHCS and its fiscal intermediary.
3)Unknown costs to provide additional Denti-Cal services, to the
extent that the changes in the bill improve participation
rates by dental providers, increasing the utilization of
Denti-Cal services (General Fund and federal funds).
Currently, the state spends about $1.2 billion per year on
Denti-Cal for adults and children. Estimates of the
utilization rates vary, but are all generally low. There are
strong indications that low reimbursement rates and cumbersome
administrative requirements on providers result in low
participation rates by providers. To the extent that the
administrative changes in the bill improve provider
participation, there could be increased utilization. For
example, for every 5% increase in annual utilization by
children, the cost would be about $35 million per year.
4)Unknown potential cost-savings due to increased use of
preventative dental services (GF and federal funds). Regular
dental care, particularly for children, is likely to prevent
dental conditions, such as cavities, from becoming more
serious health problems that require more costly interventions
later. To the extent that the bill results in increased
utilization of preventative dental services in Denti-Cal,
there are likely to be reduced costs for more serious dental
services. Whether those avoided costs are greater than the
cost of providing greater access to preventative services is
unknown.
SUPPORT: (Verified8/12/16)
California Coverage and Health Initiatives
California Dental Association
California Pan-Ethnic Health Network
California Primary Care Association
Children Now
Children's Defense Fund-California
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Children's Partnership
County Health Executives Association of California
First 5 Association of California
Little Hoover Commission
National Association of Social Workers, California Chapter
Nurse-Family Partnership
OPPOSITION: (Verified8/12/16)
None received
ARGUMENTS IN 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 calls 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 also requires 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 states
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.
ASSEMBLY FLOOR: 80-0, 5/31/16
AYES: Achadjian, Alejo, Travis Allen, Arambula, Atkins, Baker,
Bigelow, Bloom, Bonilla, Bonta, Brough, Brown, Burke,
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Calderon, Campos, Chang, Chau, Chávez, Chiu, Chu, Cooley,
Cooper, Dababneh, Dahle, Daly, Dodd, Eggman, Frazier, Beth
Gaines, Gallagher, Cristina Garcia, Eduardo Garcia, Gatto,
Gipson, Gomez, Gonzalez, Gordon, Gray, Grove, Hadley, Harper,
Roger Hernández, Holden, Irwin, Jones, Jones-Sawyer, Kim,
Lackey, Levine, Linder, Lopez, Low, Maienschein, Mathis,
Mayes, McCarty, Medina, Melendez, Mullin, Nazarian, Obernolte,
O'Donnell, Olsen, Patterson, Quirk, Ridley-Thomas, Rodriguez,
Salas, Santiago, Steinorth, Mark Stone, Thurmond, Ting,
Wagner, Waldron, Weber, Wilk, Williams, Wood, Rendon
Prepared by:Scott Bain / HEALTH / (916) 651-4111
8/16/16 9:46:15
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