SB1098 (Cannella)Page 1 of 3
SENATE COMMITTEE ONHEALTH
SenatorEd Hernandez, O.D., Chair
BILL NO: SB1098
AUTHOR: / CannellaVERSION: / April 11, 2016
HEARING DATE: / April 20, 2016
CONSULTANT: / Scott Bain
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,
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 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.
2)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.
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.
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.
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 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 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 adultswith fee-for-service Denti-Cal coverage saw a dentistin 2014, according to February 2016 DHCS data.DHCS stated that 51.8% of children 20 and under with Denti-Cal fee-for-servicecoverage had a dental visit from October2014 through September 2015. In December 2015, the Centers for Medicare and Medicaid Services (CMS), in approving the CaliforniaMedi-Cal 2020 waiver, cited a figure of37.8% of children 20 and under making adental visit during the calendar year 2014. In December 2014, the California State Auditorcited CMS data toreport that only 44% of California’s 5.1million Denti-Cal-eligible children aged 20 andunder saw a dentist from October 2012 throughSeptember 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.
3)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.
4)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.
5)Related legislation.
a)AB 2207 (Wood) requires DHCS to undertake specified 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.
6)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.
7)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.
8)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.
9)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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