BILL ANALYSIS Ó
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: SB 1098
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|AUTHOR: |Cannella |
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|VERSION: |April 11, 2016 |
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|HEARING DATE: |April 20, 2016 | | |
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|CONSULTANT: |Scott Bain |
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SUBJECT : Medi-Cal: dental services: advisory group
SUMMARY : Establishes in the Department of Health Care Services the
13-member Denti-Cal Advisory Group (Advisory Group), requires
the state dental director to serve as its chair, and specifies
the duties of the advisory group to include studying and
overseeing 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.
Existing law:
1)Establishes the Medi-Cal program, which is administered by the
Department of Health Care Services (DHCS), under which
qualified low-income individuals receive health care services,
including certain dental services, as specified.
2)Requires the Department of Public Health (DPH) to maintain a
dental program including, but not limited to, the following:
a) Development of comprehensive dental health plans
within the framework of the State Plan for Health to
maximize utilization of all resources;
b) Provide the consultation necessary to coordinate
federal, state, county, and city agency programs
concerned with dental health;
c) Encourage, support, and augment the efforts of
city and county health departments in the implementation
of a dental health component in their program plans;
d) Provide evaluation of these programs in terms of
preventive services; and,
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e) Provide consultation and program information to
the health professions, health
professional educational institutions, and volunteer
agencies.
1)Requires the director of DPH to appoint a California-licensed
dentist to administer the dental program in 2) above.
This bill:
1)Establishes in DHCS the 13 member Denti-Cal Advisory Group
(Advisory Group), requires the state dental director, to serve
as its chair, and specifies the duties of the advisory group
to include, but not be limited to, all of the following:
a) Studying and overseeing the policies and priorities
of Denti-Cal, the state Medi-Cal dental services program,
with the goal of raising the Denti-Cal utilization rate
among eligible child beneficiaries to 60% or greater;
and,
b) 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.
1)Requires the advisory group to consist of eight members
appointed by the Governor, including the following:
a) A representative from the California Dental
Association (CDA);
b) A representative from the California Dental
Hygienists' Association (CDHA);
c) A licensed social worker;
d) A representative of a health care foundation;
e) A licensed pediatrician who is qualified to assess
impacts on the overall health of children;
f) An expert on practices in the dental insurance or
health insurance markets; and,
g) Two university professors who are experts in dental
practice or the dental services field.
1)Requires two members to be appointed by the Senate Committee
on Rules, to include the following:
a) A licensed dentist; and,
b) A licensed dental hygienist.
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1)Requires two members appointed by the Assembly Speaker, to
include the following:
a) A licensed dentist; and,
b) A licensed dental hygienist.
1)Requires advisory group members, before entering upon the
discharge of his or her official duties, to take and file an
oath required under existing law and the state Constitution.
2)Requires a member of the commission to serve for a term of
three years, prohibits a limit on the number of terms a member
may serve, and permits the terms of members to be staggered so
that the terms of all members will not expire at the same
time.
3)Prohibits a member of the advisory group from being
compensated for his or her services, except requires a member
to be paid reasonable per diem and reimbursement of reasonable
expenses for attending meetings and discharging other official
responsibilities as authorized by DHCS.
4)Makes legislative findings and declarations regarding the
Denti-Cal program, the State Auditor audit in 2014 finding
that only 43.9 % of children enrolled in the Denti-Cal program
had seen a dentist in the previous year and that eleven
California counties had no Denti-Cal providers or no providers
willing to accept new child patients covered by Denti-Cal, the
need for an improved relationship between DHCS and dental care
providers, and the purpose of the evidence-based advisory
group is to guide Denti-Cal priorities, to oversee policy
decisions, and to increase annual Denti-Cal utilization rates
among children in the state to 60% or greater.
FISCAL
EFFECT : This bill has not been analyzed by a fiscal committee.
COMMENTS :
1)Author's statement. According to the author, in a state audit
of DHCS' Denti-Cal Program released in 2014, the auditor
concluded that "DHCS' information shortcomings and ineffective
actions are putting children enrolled in Medi-Cal at higher
risk of dental disease." It is unacceptable that a program
established to provide the most vulnerable population of
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children with oral health services is placing those children
at risk of dental disease. In a report entitled "Fixing
Denti-Cal," released in April 2016, the Little Hoover
Commission recommends that the Legislature create an
evidence-based advisory group to study and oversee Denti-Cal
policies and priorities to increase oversight and make sure
that Denti-Cal priorities and proposed policies are based on
best available evidence, to the benefit of its most vulnerable
beneficiaries. This bill creates such an advisory group with
the specific purpose of studying and overseeing Denti-Cal
policies and priorities to raise annual Denti-Cal utilization
rates among children to the 60% range, and providing
assistance and advice to DHCS, the Legislature, and the
Governor on proposed decisions.
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: fee-for-service (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 $1.1 billion total funds ($399.9 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. The
monthly per person rate is between $5.81 and $12.95
(monthly capitation rates are different for adults and
children and refugees) for every Medi-Cal beneficiary
enrolled in their plan. Generally, enrollees may only
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receive services from providers that are within the
plan's provider network.
Only two counties have dental managed care. In Sacramento,
almost all children and adults are mandatorily enrolled
in a DMC 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 DMC plan. If a beneficiary in Los
Angeles County does not choose to enroll in a DMC plan,
they are automatically enrolled in FFS. Denti-Cal managed
care expenditures are projected to be $147.4 million
total funds ($58.2 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
fee-for-service 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 fee-for-service
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)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
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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 pays on average 27.6% to 28.3% of
commercial rates in the Pacific Area. These rates did not
include the repeal of the 10% Denti-Cal rate reduction
required by the 2015 health budget trailer bill.
2)Little Hoover Commission report on Denti-Cal. In April 2016,
the Little Hoover Commission released a report entitled
"Fixing Denti-Cal" that stated that DHCS essentially runs a
program that is unable to attract enough dentists, unable to
provide most beneficiaries access to care and seemingly,
unable to change its ways. The report contains eleven
recommendations. Relevant to this bill are the following two
recommendations:
a) The Legislature should set a target of 66% of
children with Denti-Cal coverage making annual dental
visits. Additionally, the Legislature should conduct
oversight hearings to assess progress or lack of movement
on all initiatives designed to reach this target, and
particularly on implementation of the five-year $740
million Denti-Cal targeted incentive plan to increase
children's preventative dental visits, and ensure the
state dental director has adequate authority to see that
the Denti-Cal targeted incentive program aligns with the
2016 oral health plan; and,
b) The Legislature and the Governor should enact and
sign legislation in 2016 to create an evidence-based
advisory group for the Denti-Cal program. DHCS has much
work to do retool its Denti-Cal program to win over more
providers and provide greater access to dental care
statewide. Denti-Cal should be guided by an
evidence-based advisory group, which consists of the
state dental director and expert specialists who can
weigh in on proposed decisions and make sure they are
based on the best evidence and science and not merely on
cost. This would be especially helpful to minimize the
continual strife, confusion and even alleged harm to
beneficiaries, including special needs populations that
the Commission heard about repeatedly in public comment
during its two hearings.
1)Related legislation.
a) AB 2207 (Wood) requires DHCS to undertake specified
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activities for the purpose of improving the Denti-Cal
program, such as expediting provider enrollment, and
monitoring dental service access and utilization,
requiring Medi-Cal managed care health plan to provide
dental health screenings for eligible beneficiaries and
refer them to appropriate Medi-Cal dental providers. AB
2207 is pending in Assembly Health Committee.
b) SB 815 (Hernandez and De Leon) and AB 1568 (Bonta
and Atkins) are identical measures to implement the
provisions of the Medi-Cal 2020 Section 1115 waiver,
including the Dental Transformation Initiative (DTI). The
DTI consists of four domain areas as follows: (a)
Increase Preventive Services Utilization for Children (b)
Caries Risk Assessment and Disease Management; (c)
Increase Continuity of Care; (d) Local Dental Pilot
Programs. Additional federal funds available for the DTI
over the five years of the waiver is $375 million.
1)Prior legislation.
a) SB 694 (Padilla of 2011-12) would have established
the Statewide Office of Oral Health (Office) within DPH
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.
b) 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
impact of the restoration is $189 million for 2015-16 and
$352 million for 2016-17.
c) 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.
1)Support. The California Dental Hygienists' Association (CDHA)
writes in support that examinations by both the State Auditor
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and the Little Hoover Commission have brought to light
concerns that both patients and providers have expressed for
years. Specifically, providers do not participate in the
Denti-Cal program due to the excessive administrative burdens,
low reimbursement rates, DHCS' poor communication with
providers and DHCS' lack of understanding of how their
Denti-Cal policy decisions will impact both providers and
patients in the field. CDHA writes that this bill, if passed
and implemented correctly, should address those fundamental
issues faced by the Denti-Cal program and will go a long way
to restoring DHCS' relationship with providers and to create
sound policies for this vital program.
2)Support if amended. Maternal and Child Health Access (MCHA)
requests amendments to expand the focus of the Denti-Cal
Advisory Committee on improving utilization rates to all
Denti-Cal beneficiaries, including pregnant women, and to
include an obstetrician/ gynecologist or other prenatal care
provider and maternal and child health advocates on the
Denti-Cal Advisory Committee. MCHA writes that dental health
problems for pregnant women are linked to poor birth outcomes,
and on top of all the other access barriers, pregnant women
also face prenatal care providers who often do not make the
connection to dental, or dentists who do not know it is safe
to provide dental care during pregnancy. MCHA states CDA and
the American College of Obstetricians and Gynecologists
recently came out with joint practice guidelines during
pregnancy, and it would be important to have this crossover
issue represented on the Dental Advisory Committee.
3)Proposed author's amendments. The author is proposing
amendments to delete the requirement that the state dental
director serve as the chair of the Denti-Cal Advisory Group,
and to add two gubernatorial appointments to the group
consisting of a representative of a Denti-Cal health plan
organization and a representative of a consumer advocacy
organization.
SUPPORT AND OPPOSITION :
Support: California Dental Hygienists' Association
Oppose: None received
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