BILL ANALYSIS Ó
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|SENATE RULES COMMITTEE | SB 1098|
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THIRD READING
Bill No: SB 1098
Author: Cannella (R)
Amended: 6/1/16
Vote: 21
SENATE HEALTH COMMITTEE: 9-0, 4/20/16
AYES: Hernandez, Nguyen, Hall, Mitchell, Monning, Nielsen,
Pan, Roth, Wolk
SENATE APPROPRIATIONS COMMITTEE: 7-0, 5/27/16
AYES: Lara, Bates, Beall, Hill, McGuire, Mendoza, Nielsen
SUBJECT: Medi-Cal: dental services: advisory group
SOURCE: Author
DIGEST: This bill establishes in the Department of Health Care
Services (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.
ANALYSIS:
Existing law:
1)Establishes the Medi-Cal program, which is administered by the
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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,
e) Provide consultation and program information to the
health professions, health professional educational
institutions, and volunteer agencies.
3)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 Advisory Group, specifies
the duties of the advisory group to include all of the
following:
a) Studying 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.
2)Requires the Advisory Group to consist of ten members
appointed by the Governor, including the following:
a) A representative from the California Dental Association
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(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;
g) Two university professors who are experts in dental
practice or the dental services field;
h) A representative of a Denti-Cal health plan
organization; and,
i) A consumer advocate with experience in children's oral
health.
3)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.
4)Requires two members appointed by the Assembly Speaker, to
include the following:
a) A licensed dentist; and,
b) A licensed dental hygienist.
5)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.
6)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.
7)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.
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8)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.
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
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
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budget health trailer bill. Medi-Cal uses two different models
for delivering dental services to children: fee-for-service
(FFS) and Dental Managed Care in two counties.
3)Denti-Cal utilization. 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.
4)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 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.
5)Little Hoover Commission report on Denti-Cal. In April 2016,
the Little Hoover Commission released a report entitled
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"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.
6)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
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
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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.
FISCAL EFFECT: Appropriation: No Fiscal
Com.:YesLocal: No
According to the Senate Appropriations Committee:
1)Ongoing costs, likely between $50,000 and $150,000 per year to
provide staff support to the Advisory Group (General Fund and
federal funds). It is likely that the Advisory Group will need
staff support from DHCS to assist it with gathering
information, interpreting data and program requirements, and
formulating recommendations.
2)Unknown additional costs to provide Denti-Cal benefits to
children, to the extent that the Advisory Group is successful
in improving 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 rate for children vary, but are
all well below the goal set in the bill of 60% annual
utilization. On its own, the Advisory Group would not have the
authority to raise reimbursement rates or streamline program
requirements. However, to the extent that the Advisory Group
is able to work with DHCS to take actions that improve access
to services, there will be increased utilization costs. For
every 5% increase in annual utilization by children, the cost
would be about $35 million per year.
3)Unknown potential cost-savings due to increased use of
preventative dental services (General Fund and federal funds).
Regular dental care for children is likely to prevent dental
conditions, such as cavities, from becoming more serious
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health problems that require more costly interventions later.
To the extent that the bill results in increased utilization
of preventative dental services by children in Medi-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: (Verified5/26/16)
California Dental Hygienists' Association
Little Hoover Commission
OPPOSITION: (Verified5/26/16)
None received
ARGUMENTS IN SUPPORT: The California Dental Hygienists'
Association (CDHA) writes in support that examinations by both
the State Auditor 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.
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Prepared by:Scott Bain / HEALTH / (916) 651-4111
6/1/16 18:41:33
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