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SB-1464 Medi-Cal: benefits: enrollees with special dental care needs.(2017-2018)

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Date Published: 04/25/2018 09:00 PM
SB1464:v97#DOCUMENT

Amended  IN  Senate  April 25, 2018
Amended  IN  Senate  March 22, 2018

CALIFORNIA LEGISLATURE— 2017–2018 REGULAR SESSION

Senate Bill No. 1464


Introduced by Senator Wiener
(Coauthor: Senator Pan)(Coauthors: Senators Mitchell, Nguyen, Nielsen, and Pan)

February 16, 2018


An act to add Section 14132.235 to the Welfare and Institutions Code, relating to health care.


LEGISLATIVE COUNSEL'S DIGEST


SB 1464, as amended, Wiener. Medi-Cal: benefits: enrollees with special dental service care needs.
Existing law establishes 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 and funded by federal Medicaid program provisions. Existing law provides for a schedule of benefits under the Medi-Cal program, including certain dental services that are referred to as Denti-Cal.
This bill would require the department to develop a mechanism to identify and designate individuals with chronic medical, physical, mental, behavioral, or developmental conditions or other disabilities that complicate their dental care or require the dental provider to provide additional expertise, actions, and resources. The bill would require the department to establish Medi-Cal aid codes that identify individuals meeting these criteria as enrollees with special dental service needs. The bill would include services described in specified codes from the American Dental Association’s Current Dental Terminology dental procedure codes as covered benefits in the Denti-Cal schedule of maximum allowances, and would require the department to establish payment procedures and reimbursement rates for those codes, as specified. department, for Denti-Cal beneficiaries with special dental care needs, to provide coverage for behavior management and dental case management necessary to provide dental services as a covered benefit in the Denti-Cal program, as specified. The bill would require the department to establish reimbursement rates for those services when billed in addition to the provision of other dental services for a Denti-Cal beneficiary. The bill would not limit the provision or scope of Denti-Cal services covered under existing law. The bill would authorize the department to implement, interpret, or make specific its provisions, and any applicable federal waivers and state plan amendments, by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions, without taking regulatory action, and would require the department to subsequently adopt regulations, as specified, by July 1, 2022. The bill would require the department, commencing January 1, 2020, to provide the Legislature with semiannual status reports to the Legislature until regulations have been adopted.
Vote: MAJORITY   Appropriation: NO   Fiscal Committee: YES   Local Program: NO  

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


SECTION 1.

 (a) Denti-Cal is the Medi-Cal dental health care component program that was established soon after the 1966 creation of the Medi-Cal program.
(b) According to an audit conducted by the California State Auditor in 2014, only 43.9 percent of children enrolled in the Denti-Cal program had seen a dentist in the previous year—a utilization rate that was the 12th-worst among states that submitted data to the federal Centers for Medicare and Medicaid Services. Eleven California counties either did not have any Denti-Cal providers or did not have any providers willing to accept new child patients covered by Denti-Cal. Additionally, the Little Hoover Commission found that only 26 percent of eligible California adults with fee-for-service Denti-Cal coverage saw a dentist in 2014, according to February 2016 State Department of Health Care Services data.
(c) It is widely recognized that people with significant and chronic medical, physical, mental, behavioral, or developmental conditions or disabilities have greater challenges obtaining dental services and maintaining good oral health than other individuals. Providing care for these individuals very often requires treating providers spend additional time and furnish other resources to deliver dental services.
(d) It is the intent of the Legislature to establish eligibility and payment to address provide Denti-Cal coverage for care coordination and behavior management to improve access to dental services for Denti-Cal enrollees with special dental service needs.
SEC. 2.Section 14132.235 is added to the Welfare and Institutions Code, immediately following Section 14132.23, to read:
14132.235.

(a)The department shall develop a mechanism to identify and designate individuals with chronic medical, physical, mental, behavioral, or developmental conditions or other disabilities that complicate their dental care or require the dental provider to provide additional expertise, actions, and resources. The department shall establish Medi-Cal aid codes that identify individuals meeting these criteria as enrollees with special dental service needs.

(b)For enrollees with special dental service needs, the department shall include the services described in the following codes from the American Dental Association’s Current Dental Terminology (ADA CDT) dental procedure codes, or any updated ADA CDT codes that identify those services, as covered benefits in the Denti-Cal schedule of maximum allowances, and establish payment procedures for the service codes when enrollees receive those services:

(1)D9920: Behavior management, by report.

(2)D9991: Dental case management—addressing appointment compliance barriers.

(3)D9992: Dental case management—care coordination.

(c)The department shall establish reimbursement rates for the services identified in subdivision (b) when billed in conjunction with the provision of other dental services for an enrollee with special dental service needs, to compensate for the additional time and resources required to arrange for, provide for, and follow up on dental treatment for, these individuals.

SEC. 2.

 Section 14132.235 is added to the Welfare and Institutions Code, immediately following Section 14132.23, to read:

14132.235.
 (a) For Denti-Cal beneficiaries with special dental care needs, the department shall provide coverage for both of the following additional services necessary to provide dental services as a covered benefit in the Denti-Cal program:
(1) Behavior management.
(2) Dental case management.
(b) The department shall establish reimbursement rates for the services identified in subdivision (a) when billed in addition to the provision of other dental services for a Denti-Cal beneficiary with special dental service needs, to compensate for the additional time and resources required to arrange for, provide for, and follow-up on dental treatment for, these individuals.
(c) Dental providers shall document in the patient’s medical record the need for the additional services provided pursuant to this section.
(d) As used in this section, the following terms have the following meanings:
(1) “Behavior management” means the additional time, resources, or techniques required to perform dental procedures for an individual with special dental service needs,
(2) “Dental case management” means the time and effort spent for an individual with special dental service needs in addressing appointment compliance barriers, assisting the individual to attend scheduled appointments by solving transportation challenges or other barriers, and obtaining consent and medical consultation or clearance to perform dental procedures.
(3) “Denti-Cal beneficiary with special dental care needs” means a Denti-Cal beneficiary with chronic medical, physical, mental, behavioral, or developmental conditions or other disabilities that complicate his or her dental care or require the dental provider to provide additional expertise, actions, and resources.
(e) This section does not limit the provision of or scope of Denti-Cal services covered under existing law.
(f) 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 section, and any applicable federal waivers and state plan amendments, by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions, without taking regulatory action. By July 1, 2022, 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. Commencing January 1, 2020, the department shall provide a status report to the Legislature on a semiannual basis, in compliance with Section 9795 of the Government Code, until regulations have been adopted.