BILL ANALYSIS Ó
SB 1098
Page 1
Date of Hearing: June 28, 2016
ASSEMBLY COMMITTEE ON HEALTH
Jim Wood, Chair
SB
1098 (Cannella) - As Amended June 1, 2016
SENATE VOTE: 38-0
SUBJECT: Medi-Cal: dental services: advisory group.
SUMMARY: Establishes within the Department of Health Care
Services (DHCS) the Denti-Cal Advisory Group (Advisory Group) to
study the policies and priorities of the Denti-Cal program and
to assist and advice DHCS, the Legislature and the Governor on
the Denti-Cal program. Specifically, this bill:
1)Establishes the Advisory Group to do the following:
a) Study 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) Provide 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.
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2)Specifies the following composition of the Advisory Group:
a) The state dental director;
b) Ten members appointed by the Governor to include the
following:
i) A representative from the California Dental
Association;
ii) A representative from the California Dental
Hygienists' Association;
iii) A licensed social worker;
iv) A representative of a health care foundation;
v) A licensed pediatrician who is qualified to assess
impacts on the overall health of children;
vi) An expert on practices in the dental insurance or
health insurance markets;
vii) Two university professors who are experts in
dental practice or the dental services field;
viii) A representative of a Denti-Cal health plan
organization; and,
ix) A consumer advocate with experience in children's
oral health.
c) Two members appointed by the Senate Committee on Rules
that shall include the following:
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i) A licensed dentist; and,
ii) A licensed dental hygienist.
d) Two members appointed by the Speaker of the Assembly
that shall include the following:
i) A licensed dentist; and,
ii) A licensed dental hygienist.
e) Requires Advisory Group members, before entering upon
the discharge of their official duties, to take and file an
oath required under existing law and the state
Constitution.
f) Requires a member of the commission to serve for a term
of three years. Prohibits limits on the number of terms a
member may serve. Allows the terms of advisory group
members to be staggered so that the terms of all members
will not expire at the same time.
g) Prohibits compensation for a member of the Advisory
Group, except to be paid per diem and to be reimbursed for
reasonable expenses for attending meetings and discharging
official responsibilities, as specified.
h) Makes finding and declarations relating to the Denti-Cal
program and the need to increase utilization rates among
children.
EXISTING LAW:
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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.
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.
FISCAL EFFECT: According to the Senate Appropriations
Committee:
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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
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
COMMENTS:
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1)PURPOSE OF THIS BILL. 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 (LHC) 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 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)BACKGROUND. DHCS administers the Denti-Cal Program which
provides dental services for children under age 21 and a more
limited benefit to adults. In 2007, Denti-Cal provided
comprehensive oral health care to more than 8 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.
Denti-Cal has two separate models of delivery services to
children: fee-for-service (FFS) and Dental Managed Care (DMC).
In FFS, beneficiaries may receive dental service from any
provider who accepts Medi-Cal payments and agrees to treat
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them. Dental providers receive a payment for each service
provided to the beneficiary. FFS Denti-Cal expenditures are
projected to be $1.1 billion total funds in 2016-17. Under
the DMC program, Medi-Cal pays dental plans a capitation rate
for each beneficiary enrolled in the plan. The monthly per
person rate is between $5.81 and $12.95 (monthly capitation
rates for adults and children and refugees are different) for
every Medi-Cal beneficiary enrolled in a DMC plan. Sacramento
and Los Angeles counties have the two DMC plans. In
Sacramento, almost all children and adults are mandatorily
enrolled in a DMC plan. If a beneficiary does not choose a
DMC 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).
a) Legislative Hearings. A series of legislative hearings
in 2012 found a lack of oversight of the DMC programs in
Sacramento and Los Angeles counties by DHCS, resulting in
significant underutilization by pediatric beneficiaries.
On March 8, 2012, the Assembly Select Committee on
Workforce and Access to Care convened a meeting to examine
the state of the dental safety net, followed by a Senate
Budget Hearing on March 22, 2012, that directly examined
the Sacramento geographic managed care (GMC) dental
program. As a result, the 2012 budget trailer bill
provided for the beneficiary dental exemption process,
which allows beneficiaries who are not receiving adequate
or timely access to care to opt out of the GMC dental
program, requires DHCS to establish performance measures
and benchmarks for dental health plans, requires DHCS to
utilize dental health plan performance data for contracting
purposes, and requires the establishment of contract
incentives and disincentives, along with enacting other
oversight mechanisms.
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b) Office of the Inspector General Report. In January
2016, the federal Department of Health and Human Services
Office of the Inspector General (OIG) published a report
titled "Most Children with Medicaid in Four States are Not
Receiving Required Dental Services." The study focused on
four states: California, Indiana, Louisiana, and Maryland
and analyzed Medicaid dental (Denti-Cal in California)
claims with service dates in 2011 and 2012, beneficiary
enrollment files, and conducted structured interviews with
state officials. The OIG report found that three out of
four children did not receive all required dental services,
with one in four children failing to see a dentist at all.
All four states reported that they do not routinely track
whether children are receiving all the required services.
In addition, two of the four states had policies that do
not allow payment for particular services in accordance
with their periodicity schedules. All states reviewed
reported facing shortages of participating dental providers
and challenges in educating families about the importance
of regular dental care.
c) 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 numbers 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
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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.
d) 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
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,
and enrollment, billing, and administrative challenges.
The LHC provided 11 recommendations on how to improve the
Denti-Cal program, as follows:
i) The Legislature should set a target of 66% of
children with Denti-Cal coverage making annual dental
visits;
ii) DHCS should simplify the Denti-cal provider
enrollment forms and put them online in 2017;
iii) DHCS should overhaul the process of treatment
authorization requests;
iv) DHCS should implement a customer focused program
to improve relationships with its providers;
v) DHCS should purge outdated regulations;
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vi) The Legislature and Governor should enact and
sign legislation in 2016 to create an evidence-based
Advisory Group for the Denti-Cal program;
vii) The Legislature and Governor should fund a
statewide expansion of teledentistry and the virtual
dental home;
viii) State government, funders, and non-profits
should lead a sustained statewide "game changer" to
reorient the oral health care system for Denti-Cal
beneficiaries toward preventative care;
ix) The Legislature and DHCS should expand the
concepts of Washington State's Access to Baby and Child
Dentistry program and Alameda County's Healthy Kids,
Healthy Teeth program to more regions of California;
x) DHCS and California counties should steer more
Denti-Cal eligible patients into Federally Qualified
Health Centers with capacity to see them; and,
xi) Medical societies and non-profit organizations
should recruit more pediatricians to provide
preventative dental checkups during well-child visits.
3)Medi-Cal 2020 Waiver. The new Medi-Cal 20-20 Waiver includes
provisions to implement the "Dental Transformation Initiative"
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(DTI), which aims to improve dental health for Medi-Cal
children by focusing on high-value care, improved access, and
utilization of performance measures to drive delivery system
reform. The DTI provides incentive payments to Medi-Cal
dental providers who meet certain requirements and benchmarks.
The DTI provides $148 million annually in funding for five
years for a maximum of $740 million. More specifically, DTI
will include three domains: preventive service, caries risk
assessment and management, and continuity of care. Specific
incentive payments within each domain will be available to
qualified providers, along with messaging and education to
providers and beneficiaries about programs and efforts in
their local communities.
4)SUPPORT. The LHC indicates that Denti-Cal should be guided by
an evidence-based Advisory Group that 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. The California Dental Hygienists' Association
points out that this bill brings together providers practicing
in the field and would benefit both Denti-Cal patients and
providers.
5)SUPPORT IF AMENDED. The Maternal and Child Health Access
requests amendments to address dental health care needs during
pregnancy and include membership on the advisory committee for
OB/GYNs, midwives, and maternal and child health advocates.
To address this concern, the author is proposing to include a
maternal and child health advocate on the Advisory Group.
The California Dental Association (CDA) suggests expanding the
Advisory Group's duties to include studying and evaluating how
Denti-Cal policies align with and support the implementation
of the State Oral Health Plan. The State Oral Health Plan was
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established in 2014 and serves as a roadmap to identify
priorities, short term, intermediate, and long term goals and
objectives along with recommendations to address the burden of
disease, increase access to oral health services for high risk
populations, and to increase the oral health status of all
Californians. To address this concern, the author is
proposing to amend this bill to include this function.
Additionally, CDA suggests requiring the Director of DHCS
rather than the Governor and Legislature to make the
appointments to provide more flexibility and functionality to
the group; add a pediatric dentist and require a report to the
Legislature on the findings and recommendations of the group.
6)OPPOSITION. The Department of Health Care Services indicates
that efforts are underway to remediate the shortfalls of the
Denti-Cal Program as identified by the BSA Audit and the LHC.
DHCS points out that it "provides and participates in ongoing
opportunities for stakeholder engagement and advisory
committees, including policy discussions on dental issues,
across the state which include, but are not limited
to: the DHCS Stakeholder Advisory Committee and the Medi-Cal
Children's Health Advisory Panel, which are DHCS convened
advisory meetings which include dental representation; and the
California Department of Public Health's Oral Health Advisory
Committee. In addition, there are advisory committee meetings
held in the two counties with dental managed care: the
Medi-Cal Dental Advisory Committee held monthly in Sacramento
County and the Los Angeles Dental Stakeholder Meeting held
every other month in Los Angeles County. In all of these
forums, DHCS seeks input, feedback, advice, and
recommendations from participants, particularly as it relates
to barriers to access to care. The participants in these
groups are inclusive of clinicians, advocacy groups,
legislative and congressional staff members, beneficiaries,
and other state agency staff. The creation of a Denti-Cal
Advisory Group dedicated to the same efforts would be
duplicative." Additionally, DHCS points out that in
collaboration with a diverse workgroup comprised of children's
advocates, dental managed care plans, the state dental
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association, the State Dental Director, and representative
dental providers and academia, it is leading the
implementation of the DTI. DHCS concludes that all these
efforts will result in achieving similar outcomes to those
identified in this bill.
7)RELATED LEGISLATION.
a) AB 648 (Low) establishes the Virtual Dental Home program
to expand the virtual dental home model of community-based
delivery of dental care and directs the California Health
Facilities Financing Authority to administer the grant
program. AB 648 is on the Senate Inactive File.
b) AB 1568 (Bonta and Atkins) implements the provisions of
the Medi-Cal 2020 waiver and specifically include the
provisions relating to the DTI. AB 1568 is pending in the
Assembly for concurrence in Senate amendments.
c) AB 2108 (Waldron) requires DHCS, on or before January 1,
2018, to submit a report to the Legislature on the cost and
feasibility of restoring full adult dental services as a
covered benefit under the Medi-Cal Program and sunsets
those provisions on January 1, 2019. AB 2108 is pending in
this Committee.
d) AB 2207 (Wood) makes changes to the Denti-Cal provider
enrollment and disenrollment process, increases access and
utilization oversight responsibility of DHCS over Denti-Cal
contracts, and aligns Denti-Cal FFS and DMC annual and
quarterly data reporting requirements. AB 2207 is pending
in Senate Health Committee.
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8)PREVIOUS 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
fiscal 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 DMC 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.
9)POLICY CONCERNS.
a) Functions of the Advisory Group. In addition to
assisting and advising on the Denti-Cal program, the
Committee may wish to amend this bill to also require the
Advisory Group to study and evaluate how Denti-Cal policies
align with and support the implementation of the State Oral
Health Plan. Additionally, the Committee may wish to
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clarify that the Advisory Group cannot take positions on
legislation.
a) Report to the Legislature. The Committee may wish to
recommend that the Advisory Group report any findings to
the Legislature.
b) Sunset. To assess the continued utility of the Advisory
Group, the Committee may wish to sunset this bill on
January 1, 2022.
c) Membership of the Advisory Group. Under this bill, the
Advisory Group will be made up of 15 members, but some of
the appointments are overlapping. For example, one member
must be an expert on practices in the dental insurance or
health insurance markets and there must be a representative
of a Denti-Cal health plan organization. Additionally, the
Senate Rules Committee and Speaker of the Assembly each
appoint a dental hygienist and dentist in addition to a
representative from the California Dental Association and
the Dental Hygienists' Association to be appointed by the
Governor. To eliminate duplication, the Committee may wish
to revise the membership of the Advisory Group as follows:
The Advisory Group shall consist of the following
members:
(1) The state dental director.
(2) Ten Seven members appointed by the Governor that
shall include the following:
(A) A representative from the California Dental
Association.
(B) A representative from the California Dental
Hygienists' Association.
(C) A licensed social worker
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(D) A representative of a philanthropic health care
foundation.
(E) A licensed pediatrician who is qualified to assess
impacts on the overall health of children.
representative of the California Society of Pediatric
Dentistry
( F) An expert on practices in the dental insurance or
health insurance markets.
(G) Two university professors and/or educators who are
experts in dental practice or the dental services
field.
(H) A representative of a Denti-Cal health plan
organization.
(I) A consumer advocate with experience in children's
oral health
(3) A maternal and child health advocate with experience
in the link between the mother's access to oral health
care during pregnancy and postpartum and the child's
improved access to oral health care to be appointed by
the Senate Committee on Rules. Two members appointed by
the Senate Committee on Rules that shall include the
following:
(A) A licensed dentist.
(B) A licensed dental hygienist.
(4) A consumer advocate with experience in adult dental
health to be appointed by the Speaker of the Assembly
Two members appointed by the Speaker of the Assembly
that shall include the following:
(A) A licensed dentist.
(B) A licensed dental hygienist.
d) Technical Amendments. On page 3 line 31, strikeout
"commission" and insert "advisory group."
REGISTERED SUPPORT / OPPOSITION:
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Support
California Dental Hygienists' Association
California Pan-Ethnic Health Network
Little Hoover Commission
Opposition
California Department of Health Care Services
Analysis Prepared by:Rosielyn Pulmano / HEALTH / (916)
319-2097