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SB-508 Medi-Cal: dental health.(2017-2018)

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Date Published: 04/07/2017 04:00 AM
SB508:v97#DOCUMENT

Amended  IN  Senate  April 06, 2017
Amended  IN  Senate  March 20, 2017

CALIFORNIA LEGISLATURE— 2017–2018 REGULAR SESSION

Senate Bill No. 508


Introduced by Senator Roth

February 16, 2017


An act to amend Section 14149.8 of, and to add Article 2.93 (commencing with Section 14091.40) to Chapter 7 of Part 3 of Division 9 of of, the Welfare and Institutions Code, relating to Medi-Cal.


LEGISLATIVE COUNSEL'S DIGEST


SB 508, as amended, Roth. Medi-Cal: dental health.
Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed by, and funded pursuant to, federal Medicaid program provisions. Existing law provides for a schedule of benefits provided under the Medi-Cal program, which includes certain dental services that are referred to as the Medi-Cal dental program, or Denti-Cal. Existing law requires the department to work with dental managed care plans that contract with the department for the purposes of implementing Denti-Cal, as specified.
This bill would authorize the department, no sooner than July 1, 2019, and to the extent that federal financial participation is available and any necessary federal approvals have been obtained, to authorize a Dental Health Collaboration Pilot Program for Medi-Cal beneficiaries enrolled in Medi-Cal managed care health plans that serve the County of Riverside, the County of San Bernardino, or both of those counties, using a hybrid collaboration model that coordinates the efforts of participating health plans, dental managed care plans, and the department. The bill would authorize the department to undertake specified activities in support of the pilot program, such as providing technical assistance to participating health plans and dental managed care plans and providing an innovative payment structure, including payment incentives, that facilitates the pilot program’s health and dental objectives. The bill would require participating health plans and dental managed care plans to collaborate with each other and would require a dental managed care plan to collaborate with the department on the design and implementation of the pilot program for an operating period of up to 5 years. The bill would require participating health plans and dental managed care plans to, among other things, deliver Denti-Cal services to participating beneficiaries, engage in specified beneficiary outreach activities, and coordinate patient care. The bill would authorize a participating dental managed care plan to implement and demonstrate innovative payment methods, including incentive payments. The bill would authorize a participating health plan or dental managed care plan to terminate its participation in the program by giving specific notice to the department, beneficiaries, and participating health plans or dental managed care plans, as applicable.
This bill would require a Medi-Cal dental managed care plan to work with the department to ensure access to, and the provision of, quality dental services to Medi-Cal beneficiaries, and would also require a managed care plan in connection therewith to undertake specified activities, such as ensuring enrolled beneficiaries have access to primary and specialist dental care, maintaining a utilization management program, and conducting or participating in quality improvement projects.
Vote: MAJORITY   Appropriation: NO   Fiscal Committee: YES   Local Program: NO  

The people of the State of California do enact as follows:


SECTION 1.

 Article 2.93 (commencing with Section 14091.40) is added to Chapter 7 of Part 3 of Division 9 of the Welfare and Institutions Code, to read:
Article  2.93. Dental Health Collaboration Pilot Program

14091.40.
 The following definitions shall apply for the purposes of this article:
(a) “Dental managed care plan” means a plan that contracts with the department for the purpose of implementing the Medi-Cal dental program, which includes, but is not limited to, contracts authorized pursuant to Sections 14087.46, 14089, and 14104.3 that provide beneficiaries with access to dental plan liaisons to assist in the coordination of care for enrolled members.
(b) “Oral health care” means health care that works toward a state of being free from chronic mouth and facial pain, oral and throat cancer, oral sores, birth defects such as cleft lip and palate, periodontal (gum) disease, tooth decay and tooth loss, and other diseases and disorders that affect the oral cavity.
(c) “Oral hygiene education” means education on the practice brushing and flossing to keep the mouth clean and to prevent tooth decay and gum disease.

14091.41.
 The Legislature finds and declares all of the following:
(a) Untreated tooth decay affects more children than any other chronic infectious disease in the United States, leading to pain and suffering, loss of school days, and even death, despite being a largely preventable disease, as noted by the Pediatric Oral Health Research and Policy Center.
(b) Children at increased risk of developing caries often lack access to dental care and many do not have good home care prevention practices.
(c) According to the California State Auditor’s report of December 2014, in 2013 less than one-half of the children enrolled in California’s Medi-Cal dental program, also known as Denti-Cal, were able to access basic dental care.
(d) Recent estimates by the State Department of Health Care Services indicate that only 25 percent of adults enrolled in Denti-Cal accessed any dental treatment benefits during 2014, even though adult benefits were partially restored.
(e) The Medi-Cal Dental Services Rate Review, dated July 1, 2015, reflects that California’s reimbursement rates for Denti-Cal were considerably lower than the comparable states of Florida, New York, and Texas, and only 31 percent of the national average for commercial dental insurance.
(f) Research has identified associations between chronic oral infections and diabetes, heart and lung disease, stroke, and poor birth outcomes.
(g) The federal Centers for Medicare and Medicaid Services (CMS) is encouraging states to emphasize new approaches to integrated whole-person care, including dental care, as well as developing innovative payment methods for state Medicaid programs.
(h) Several states have demonstrated successful outcomes with redesigning their dental programs under Medicaid.
(i) Innovative models of health and dental collaboration and innovative payment methods need to be tested in California to improve the overall health of Medi-Cal beneficiaries and to ensure an efficient and effective Denti-Cal program.
(j) Documented experience in the Counties of San Bernardino and Riverside has identified a lack of dentists accepting new Medi-Cal beneficiaries and difficulty for Medi-Cal beneficiaries in navigating dental providers.
(k) Strategic payment incentive approaches to attract and retain dentists and effectively drive the timely and appropriate use of dental services have been effective in several state Medicaid programs.

14091.42.
 (a) It is the intent of the Legislature to establish the Dental Health Collaboration Pilot Program to test and examine the efficacy of using a hybrid collaboration model to provide comprehensive oral health care, including oral hygiene education, prevention services, and dental treatment, under the auspices of a dental managed care plan and in collaboration with a health plan that is a Medi-Cal managed care health plan that serves the County of San Bernardino or the County of Riverside, or both of those counties.
(b) It is the intent of the Legislature for the Dental Health Collaboration Pilot Program to do all of the following, as permitted by federal law:
(1) Design and implement an oral hygiene education collaborative to provide parents, caregivers, children, and adults with applicable information and motivation to adopt positive oral health behaviors.
(2) Provide direct linkage between health care and dental care for Medi-Cal beneficiaries, including an ongoing relationship with the beneficiary and dental provider.
(3) Establish objectives for improving access to comprehensive oral health care, including access to dental prevention services and pediatric dentistry.
(4) Establish objectives for improving dental utilization, as medically indicated, for Medi-Cal beneficiaries.
(5) Test innovative payment models.
(6) Enroll eligible Medi-Cal beneficiaries into the pilot program on a voluntary basis.
(7) Achieve improved health and dental outcomes for enrolled Medi-Cal beneficiaries.
(8) Collect, measure, and analyze data in collaboration with the department.
(9) Conduct ongoing quality improvement to facilitate attainment of pilot program objectives.

14091.43.
 (a) No sooner than July 1, 2019, and subject to any necessary federal approvals and in accordance with this article, the department may authorize a Dental Health Collaboration Pilot Program for Medi-Cal beneficiaries.
(b) The department may authorize implementation of the pilot program for a period of up to five years.
(c) The department may seek any federal approvals as necessary, including state plan amendments or waivers.
(d) The department may provide an innovative payment structure through the pilot program to specifically facilitate health and dental objectives as identified in the pilot program, including health care savings attributable to improved dental access and the use of payment incentives to facilitate dental provider participation and the cost-effective utilization of oral health care services.
(e) The department may facilitate and assist in any necessary exchange of data between the participating health plan and the participating dental managed care plan as needed to implement the pilot program.
(f) The department may provide technical assistance as necessary to participating health plans and participating dental managed care plans.

(g)The department may develop specific contract language with a participating health plan for the purposes of implementing the Dental Health Collaboration Pilot Program that shall be incorporated into the contracts of each affected health plan.

(h)

(g) The department may develop specific contract language with a participating dental managed care plan for the purposes of implementing the Dental Health Collaboration Pilot Program that shall be incorporated into the contracts of each affected dental managed care plan.

14091.44.
 (a) A health plan that is a Medi-Cal managed care plan and that serves the County of San Bernardino or the County of Riverside, or both of those counties, may choose to participate in the Dental Health Collaboration Pilot Program in accordance with this section.
(b) A health plan that chooses to participate in the pilot program shall do all of the following: may participate as follows:
(1) Engage with the department and the participating dental managed care plan as deemed appropriate to design and implement the pilot program for an operating period of up to five years.
(2) In collaboration with the department and the participating dental managed care plan, as deemed appropriate, identify and establish core objectives for improving dental utilization and overall health care for Medi-Cal beneficiaries who opt to participate in the pilot program.
(3) Collaborate with the participating dental managed care plan to engage in consistent and ongoing outreach to Medi-Cal beneficiaries for the purpose of obtaining their participation in medically appropriate usage of Denti-Cal and enrollment into participation in the pilot program. Outreach activities may include, but are not limited to, the following:
(A) Identifying At the initial dental screening, as described in paragraph (1) of subdivision (g) of Section 14149.8, identifying Medi-Cal beneficiaries who are not utilizing or underutilizing Denti-Cal program services, as appropriate.
(B) Providing notification to beneficiaries regarding the pilot program, as appropriate.
(C) Participating in health and dental community-based events.
(4) Provide linkage with linkage, as applicable, between the participating dental managed care plan to ensure a warm handoff of identified and Medi-Cal beneficiaries who have opted into the pilot program.
(5) Actively engage Engage in patient care coordination functions with the participating dental managed care plans, including, but not limited to, the following: advising patients of the availability of the Dental Health Collaboration Pilot Program, as applicable.

(A)Identifying, as applicable, patients with special health care and dental care needs.

(B)Developing an overall health and dental care strategy that meets the patient’s medical needs.

(C)Coordinating and monitoring patient care with the goal of achieving optimum health care and dental care outcomes in an efficient and cost-effective manner.

(D)Arranging for patient consultations and postreview activities for continued quality improvement and improved patient compliance with the patient’s health and dental plan.

(6) Collect, measure, and analyze data in collaboration Collaborate with the department and participating dental managed care plans to identify lessons learned and pilot program achievements. The participating dental managed care plan shall be the lead entity in this collaboration with the department.

14091.45.
 (a) A dental managed care plan that chooses to participate in the Dental Health Collaboration Pilot Program in accordance with this section, and that is under contract with the department to serve Medi-Cal beneficiaries in the County of San Bernardino, the County of Riverside, or both of those counties, shall do all of the following:
(1) Engage with the department and the participating health plan as deemed appropriate to design and implement the pilot program for an operating period of up to five years.
(2) In collaboration with the department and participating health plans, as deemed appropriate, identify and establish core objectives for improving dental utilization and overall health care for Medi-Cal beneficiaries who opt to participate in the pilot program.
(3) Collaborate with the participating health plans plans, as deemed appropriate, to engage in consistent and ongoing outreach to Medi-Cal beneficiaries for the purpose of obtaining their participation in medically appropriate usage of Denti-Cal and enrollment into the pilot program. Outreach activities may include, but are not limited to, the following:
(A) Identifying Medi-Cal beneficiaries who are not utilizing or underutilizing Denti-Cal program services.
(B) Providing notification regarding the pilot program, as appropriate.
(C) Scheduling appointments and providing regular appointment reminders.
(D) Providing interpreters.
(E) Providing transportation.
(F) Facilitating communication between the Medi-Cal beneficiary and his or her dental provider.
(G) Participating in health and dental community-based events.
(4) Provide culturally appropriate oral hygiene education programs with special emphasis on underserved children.
(5) Provide linkage with the participating health plan plan, as applicable, to ensure a warm handoff of identified Medi-Cal beneficiaries who have opted into the pilot program.
(6) Actively engage in patient care coordination functions with the participating health plan, as applicable, including, but not limited to, the following:
(A) Identifying, as applicable, patients with special health care and dental care needs.
(B) Engaging with referred patients to ensure that a high level, integrated, and personalized dental care plan is implemented.
(C) Developing an overall health and dental care strategy that meets the patient’s medical needs.
(D) Coordinating and monitoring patient care with the goal of achieving optimum health care and dental care outcomes in an efficient and cost-effective manner.
(E) Arranging for patient consultations and post-review activities for continued quality improvement and improved patient compliance with the patient’s health and dental plan.
(7) Monitor dental providers for performance and outcomes, including ongoing quality improvement as necessary.
(8) Collect, measure, and analyze data in collaboration with the department, the participating health plan plan, as necessary, and dental providers to identify lessons learned and pilot program achievements. The participating dental managed care plan shall be the lead entity in this collaboration with the department and dental providers.
(b) Upon the approval of the department, a participating dental managed care plan may implement and demonstrate innovative payment methods designed to provide actuarially sound reimbursement to dental providers, along with incentive payments the that recognize established outcome measures and objectives.

14091.46.
 A health plan may terminate its participation in the pilot program by notifying the department at least 120 days before the termination. The health plan shall give participating Medi-Cal beneficiaries and dental managed care plans at least 90 days’ notice of termination.

14091.47.
 A dental managed care plan may terminate its participation in the pilot program by notifying the department at least 120 days before the termination. The dental managed care plan shall give participating Medi-Cal beneficiaries and health plans at least 90 days days’ notice of termination.

14091.48.
 Contracts entered into pursuant to this article may be on a bid or nonbid basis, and shall be exempt from Chapter 2 (commencing with Section 10290) of Part 2 of Division 2 of the Public Contract Code.

14091.49.
 This article shall not be construed to limit or eliminate services provided by the Medi-Cal program or Denti-Cal.

14091.50.
 This article shall be implemented only to the extent that federal financial participation is available and any necessary federal approvals have been obtained.

14091.51.
 Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this article by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions, without taking regulatory action.

SEC. 2.

 Section 14149.8 of the Welfare and Institutions Code is amended to read:

14149.8.
 (a) The department shall expedite the enrollment of Medi-Cal dental providers by streamlining the Medi-Cal provider enrollment process. The department shall pursue and implement all of the following activities, to the extent permitted by federal law:
(1) Create a dental-specific enrollment form.
(2) Pursue an alternative automatic enrollment process for a provider already commercially credentialed by either a dental fee-for-service contractor or an administrative services contractor for the purpose of providing services as a commercial provider.
(3) Discontinue requiring providers to resubmit an enrollment application that has been deemed incomplete if the missing information is available elsewhere within the application packet.
(4) To the extent that the department expedites the enrollment of Medi-Cal dental providers by streamlining the Medi-Cal provider enrollment process, the department shall publish the criteria for those processes in applicable provider bulletins and manuals.
(b) (1) The department shall maintain the provider network on a monthly basis by deactivating a billing provider who has not, over a continuous 12-month period, submitted a claim for reimbursement for services rendered.
(2) Prior to deactivating a provider described in paragraph (1), the department shall send a notice to the provider informing the provider that the provider shall be deactivated from the dental program unless the provider requests reactivation within six months after the date of the notice. The department shall not disenroll a provider until six months after the date of that notice. This paragraph shall not be implemented until the date the department implements and programs the necessary system changes to the California Dental Medicaid Management Information Systems to implement this paragraph, or no sooner than July 1, 2017, whichever is later.
(3) In order to improve the quality of the dental provider network, the department also shall exercise additional measures as appropriate and permitted by law, including, but not limited to, temporary suspensions. The parameters and criteria developed by the department for additional measures for deactivations and disenrollments shall be published in applicable provider bulletins and manuals.
(c) (1) The department shall monitor access and utilization of Medi-Cal dental services in the fee-for-service and managed care delivery systems to assess opportunities to improve access and utilization, including an annual review of the treatment authorization review process.
(2) The department shall assess opportunities to develop and implement innovative payment reform proposals within the Medi-Cal dental programs.
(d) The department shall explore additional opportunities to improve the Medi-Cal Dental Program, in consultation with stakeholders and as deemed appropriate by the department and to the extent permitted by federal law, including, but not limited to, the following:
(1) Aligning the provision of dental anesthesia services with that of medical anesthesia services, including the ability to bill for applicable facility fees and ancillary services.
(2) Adjusting other utilization controls for specialty services, as appropriate, to promote access to care while still protecting program integrity.
(3) Expanding the scope of beneficiary outreach activities required by an entity that is contracted with the department to more broadly address underutilization throughout the state.
(e) Prior to implementing an action pursuant to subdivision (d), the department shall post the proposed action on its Internet Web site at least 30 days before implementation.
(f) The department shall work with dental managed care plans that contract with the department for the purposes of implementing the Medi-Cal Dental Program, which includes, but is not limited to, contracts authorized pursuant to Sections 14087.46, 14089, and 14104.3, to provide beneficiaries with access to dental plan liaisons to assist in the coordination of care for enrolled members.
(g) A Medi-Cal dental managed care plan shall work with the department to ensure access to, and the provision of, quality dental services to Medi-Cal beneficiaries, and its activities in connection therewith shall include, but not be limited to, all of the following:
(1) Maintaining licensure pursuant to the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code).
(2) Ensuring each enrolled Medi-Cal beneficiary has an available primary care dentist.
(3) Ensuring each enrolled Medi-Cal beneficiary has access to specialists for medically necessary covered services.
(4) Implementing and actively maintaining a utilization management program to ensure appropriate processes are used to review and approve the provision of medically necessary dental services as identified in the Manual of Criteria and Schedule of Maximum Allowances contained in the Medi-Cal Dental Program Provider Handbook.
(5) Maintaining a full-time dentist as dental director pursuant to Section 53913.5 of Title 22 of the California Code of Regulations.
(6) Complying with Title 28 of the California Code of Regulations, including Sections 1300.67.2 and 1300.70, regarding accessibility of services and requirements for ongoing quality assurance systems, respectively.
(7) Monitoring contracting dental providers using quality improvement thresholds as established by the department.
(8) Developing and submitting to the department an annual quality improvement report that describes activities undertaken and evaluates areas of success and needed improvements.
(9) Conducting or participating in quality improvement projects as approved by the department.

(g)

(h) A Medi-Cal managed care health plan shall do all of the following:
(1) Provide dental screenings for every eligible beneficiary as a part of the beneficiary’s initial health assessment.
(2) Ensure that an eligible beneficiary is referred to an appropriate Medi-Cal dental provider.
(3) Identify plan liaisons available to dental managed care contractors and dental fee-for-service contractors to assist with referrals to health plan covered services.

(h)

(i) (1) To increase the efficiency and timeliness of changes, any contract amendment, modification, or change order to any contract entered into by the department for the purposes of implementing the state Medi-Cal Dental Program shall be exempt, except as provided in paragraph (2), from Part 2 (commencing with Section 10100) of Division 2 of the Public Contract Code, as well as Sections 11545 and 11546 of the Government Code, in addition to any policies, procedures, or regulations authorized by those provisions.
(2) Paragraph (1) shall not exempt the department from establishing a competitive bid process for awarding new contracts pursuant to Section 14104.3, as well as for awarding new dental contracts pursuant to Sections 14087.46 and 14089.

(i)

(j) Prior to implementing any change pursuant to this section, the department shall consult with, and provide notification to, stakeholders, including representatives from counties, local dental societies, nonprofit entities, legal aid entities, and other interested parties.

(j)

(k) (1) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department, without taking any further regulatory action, shall implement, interpret, or make specific policies and procedures pertaining to the dental fee-for-service program and dental managed care plans, as well as applicable federal waivers and state plan amendments, including the provisions set forth in this section, by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions until regulations are adopted.
(2) No later than December 31, 2018, the department shall adopt regulations in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. Beginning six months after the effective date of this section, and notwithstanding Section 10231.5 of the Government Code, the department shall provide a status report to the Legislature on a semiannual basis until regulations have been adopted.

(k)

(l) This section shall be implemented only to the extent that all of the following occur:
(1) The department obtains any federal approvals necessary to implement this section.
(2) The department obtains federal matching funds to the extent permitted by federal law.