Code Section Group

Welfare and Institutions Code - WIC

DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.8]

  ( Division 9 added by Stats. 1965, Ch. 1784. )

PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771]

  ( Part 3 added by Stats. 1965, Ch. 1784. )

CHAPTER 7. Basic Health Care [14000 - 14199.60]

  ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )

ARTICLE 4.10. Medi-Cal Dental Program [14149.8- 14149.8.]
  ( Article 4.10 added by Stats. 2016, Ch. 613, Sec. 2. )

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 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) In accordance with Section 438.230(c)(3) of Title 42 of the Code of Federal Regulations, effective for the rating period for contracts with dental managed care plans beginning on or after July 1, 2017, the department shall require that the dental managed care plans provide that the department, the federal Centers for Medicare and Medicaid Services, the federal Office of the Inspector General, the federal Comptroller General, and their designees may, at any time, inspect and audit any records or documents of the managed care entity, or its subcontractors, and may, at any time, inspect the premises, physical facilities, and equipment where Medicaid-related activities or work is conducted. The right to audit under this subdivision exists for 10 years from the final date of the contract period or from the date of completion of any audit, whichever is later.

(i) In accordance with Section 438.230(c)(3) of Title 42 of Code of Federal Regulations, effective for the rating period for contracts with dental managed care plans beginning on or after July 1, 2017, the department shall require that the dental managed care plan contractors retain, and require its subcontractors to retain, as applicable, all of the following information for a period of no less than 10 years:

(1) Enrollee grievance and appeal records.

(2) Base data.

(3) Medical loss ratio reports.

(4) The data, information, and documentation specified in federal Medicaid regulations, including Sections 438.604, 438.606, 438.608, and 438.610 of Title 42 of the Code of Federal Regulations.

(j) (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.

(k) 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.

(l) (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.

(m) 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.

(Amended by Stats. 2017, Ch. 511, Sec. 28. (AB 1688) Effective January 1, 2018.)

WICWelfare and Institutions Code - WIC4.10