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

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Date Published: 06/19/2018 09:00 PM
SB1464:v96#DOCUMENT

Amended  IN  Assembly  June 19, 2018
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
(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 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. Denti-Cal, and dental managed care plans.
This bill would require the department, for Denti-Cal and dental managed care plan 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 a payment adjustment to providers in the Denti-Cal program, program and for dental managed care plans, 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 require the department to seek any necessary approvals from the federal Centers for Medicare and Medicaid Services to implement the bill. The bill would require the department to implement its provisions 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. 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. 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 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 to spend additional time and furnish other resources to deliver dental services. Denti-Cal’s current reimbursement structure is based on a healthier population and does not acknowledge the additional costs of providing care for persons with special dental care needs and inhibits providers’ ability to receive proper payment for their care. As seen in the medical benefit in Medicaid, Medicare, and other payers, payment adjustments can be used to compensate providers that treat higher need patients for the extra time and resources needed to complete these patients’ care. There is currently no such payment adjustment in Denti-Cal for providers that treat patients with special dental care needs.
(d) It is the intent of the Legislature to provide Denti-Cal coverage for care coordination and behavior management to improve access to dental services for Denti-Cal enrollees a payment adjustment to Denti-Cal and dental managed care providers to address the extra time and management needed to treat patients with special dental service needs. care needs, as described in this section.

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 and dental managed care plan 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: a payment adjustment to providers.

(1)Behavior management.

(2)Dental case management.

(b) The department shall establish reimbursement rates for the services the payment adjustment identified in subdivision (a) when billed in addition to the provision of other dental services for a Denti-Cal beneficiary or dental managed care plan 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.
(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)

(1) “Denti-Cal or dental managed care plan beneficiary with special dental care needs” means a Denti-Cal or dental managed care plan 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.
(2) “Payment adjustment” means the additional reimbursement provided to Denti-Cal and dental managed care plan providers treating patients with special dental care needs. This payment is an adjustment to compensate for the extra time and resources needed to complete the care needed for Denti-Cal and dental managed care plan beneficiaries with special dental care needs that would not otherwise have been expended on healthier Denti-Cal and dental managed care plan beneficiaries.
(e) This section does not limit the provision of of, or scope of of, Denti-Cal or dental managed care plan services covered under existing law.
(f) 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.

(f)

(g) 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.