Today's Law As Amended

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AB-316 Medi-Cal: benefits: beneficiaries with special dental care needs.(2019-2020)



SECTION 1.
 (a) The Medi-Cal dental care program was established soon after the 1966 creation of the Medi-Cal program. The Medi-Cal dental program delivers dental services through a fee-for-service model. Dental services are also provided to beneficiaries enrolled in Medi-Cal dental managed care plans.
(b) According to an audit conducted by the California State Auditor in 2014, only 43.9 percent of children enrolled in the Medi-Cal dental 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 Medi-Cal dental program providers or did not have any providers willing to accept any new patients if the children received coverage through the Medi-Cal dental program. Additionally, the Little Hoover Commission found that only 26 percent of eligible California adults with Medi-Cal dental 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 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 to spend additional time and furnish other resources to deliver dental services. The Medi-Cal dental program’s current reimbursement structure is based on a healthier population, does not acknowledge the additional costs of providing care for persons with special dental care needs, and inhibits providers’ ability to receive proper compensation for their care. With regard to medical health care, as seen in Medicaid, Medicare, and other payer systems, enhanced reimbursement can be used to compensate providers that treat special dental care needs patients for the extra time and resources needed to complete these patients’ care. There is currently no permanent benefit in the Medi-Cal dental program for providers that treat patients with special dental care needs.
(d) For purposes of improving access to dental care for Medi-Cal dental program beneficiaries with special dental care needs, it is the intent of the Legislature to codify a special needs treatment and management benefit for the Medi-Cal dental program.

SEC. 2.

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

14132.235.
 (a) For purposes of improving access to dental care for Medi-Cal dental program beneficiaries with special dental care needs, as defined in paragraph (1) of subdivision (b), the department shall implement a special needs treatment and management benefit subject to utilization controls.
(b) As used in this section, the following terms have the following meanings:
(1) “Medi-Cal dental program beneficiary with special dental care needs” means a Medi-Cal dental program beneficiary who requires additional time for a provider to perform dental services due to the presence of a medical, physical, behavioral, or developmental condition that prohibits the beneficiary from adequately responding to a provider’s attempts to perform dental services.
(2) “Dental services” means dental benefits included in the Medi-Cal dental program schedule of benefits.
(c) A Medi-Cal dental program provider shall document in the patient’s medical record the necessity for any additional time to be expended to treat a Medi-Cal dental program beneficiary with special dental care needs.
(d) A request for reimbursement of the special needs treatment and management benefit shall be by a posttreatment report with written documentation, and shall include findings that support the existence of special dental care needs. That documentation shall include the medical diagnosis of a patient’s condition, a description of additional steps undertaken by the provider in their attempt to successfully treat the patient, and the reason for the need of additional time for a dental visit.
(e) The special needs treatment and management benefit is provided for four visits in a 12-month period for a Medi-Cal dental program beneficiary with special dental care needs.
(f) This section does not limit the provision of, or scope of, Medi-Cal benefits.
(g) This section does not preclude the department from establishing multiple billing codes with different criteria to implement the special needs treatment and management benefit.
(h) The department shall seek any necessary approvals from the federal Centers for Medicare and Medicaid Services to implement this section. The department shall implement this section only in a manner that is consistent with federal Medicaid law and regulations, and only to the extent that the necessary approvals are obtained and federal financial participation is not jeopardized.
(i) 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.