BILL ANALYSIS                                                                                                                                                                                                    



                                                                    AB 2207


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          CONCURRENCE IN SENATE AMENDMENTS


          AB  
          2207 (Wood)


          As Amended  August 15, 2016


          Majority vote


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          |ASSEMBLY:  | 80-0 |(May 31, 2016) |SENATE: | 38-0 |(August 18,      |
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          Original Committee Reference:  HEALTH




          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 quarterly (instead of annual) posting of the data of  
            the Denti-Cal FFS and DMC 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.










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          2)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 DMC plans.


          3)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.


          4)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.


          5)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.


          6)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.


          7)Requires DHCS to explore additional opportunities in  
            consultation with stakeholders, to improve the Denti-Cal, as  
            specified.


          8)Allows DHCS to implement, interpret, or make specific policies  
            and procedures by means of all-county letters, plan letters,  








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            plan or provider bulletins, or similar instructions, requires  
            DHCS to thereafter adopt regulations, and requires DHCS to  
            update the legislature until regulations are adopted. 


          9)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.


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


          The Senate amendments 


          1)Require DHCS, no sooner than July 1, 2019, to annually publish  
            the following utilization data from the preceding calendar  
            year and post the information on its internet Web site:


             a)   Number of patients seen on a per-provider basis;


             b)   Number of annual preventative dental services dental  
               treatment services, examinations, and oral health  
               evaluations rendered by each provider during each calendar  
               year; and,


             c)   The number of beneficiaries who received general  
               anesthesia services.


          2)Require DHCS to maintain the provider network on a monthly  
            basis and clarify procedures regarding the deactivation and  
            disenrollment of Denti-Cal providers. 


          3)Specify that a provider who has not submitted a claim for  








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            reimbursement of services rendered in one continuous 12 month  
            period be deactivated and, at the time of deactivation,  
            require DHCS to send a notification to the provider informing  
            them of their ability to request reactivation.


          4)Specify that a Denti-Cal provider be disenrolled 6 months  
            after DHCS has notified them of their deactivation status.


          5)Make provisions in 2) through 4) above, operational once DHCS  
            has implemented necessary system changes to the California  
            Dental Medicaid Management Information or July 1, 2017,  
            whichever is later.


          6)Specify requirements for DHCS to work with Denti-Cal managed  
            care plans that contract with DHCS to provide beneficiaries  
            with access to dental plan liaisons to assist with referrals  
            to health plan covered services.


          7)Codify 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 of Medi-Cal 2020, the state's  
            Section 1115 Medicaid waiver.


          FISCAL EFFECT:  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 the Department of Health Care Services  
            (General Fund and federal funds).


          2)Unknown costs to make administrative changes to the system for  
            enrolling Denti-Cal providers (General Fund and federal  








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            funds).  This bill requires the Department 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.  
             The Department has already begun 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 to process  
            enrollment applications, which are currently very labor  
            intensive to the Department 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, 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 (General Fund 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  








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            greater than the cost of providing greater access to  
            preventative services is unknown.


          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.  


          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  








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          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. 


          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  








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          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.  




          Analysis Prepared by:                                             
                          Paula Villescaz / HEALTH / (916) 319-2097  FN:   
          0004210