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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