The California Society of Pediatric Dentistry is the state’s leading advocate and recognized authority on oral health issues affecting infants, children, adolescents and patients with special health care and developmental needs. The Society interacts with the state legislature, regulatory bodies, licensing bureaus, institutions of dental education, media outlets, and policy makers at all levels of public and private participation to promote and ensure optimal pediatric oral health in the state.
In what I reported as a positive development for undercompensated providers in the previous issue of The Bulletin, the Governor and the legislature reached agreement in the fiscal 2015-2016 state budget to exempt dental services from the 10% across-the-board Medi-Cal payment reductions applied in 2013, beginning July 1 of this year. Implementation of the prospective rate restoration, however, is still being delayed pending approval by the Centers for Medicare and Medicaid Services (CMS). Until that federal approval is granted, payments to Denti-Cal providers will continue to reflect the 10% reduction. Once CMS approval is acquired, the state will correct underpayments to Denti-Cal providers made for services provided since July 1. It is unclear whether this will be done by issuance of a check or by application to future claims.
While this should be viewed as a positive step toward rebuilding our state Medicaid Dental Program, dental reimbursement rates in California are still at the same level as they were in the year 2000. A recent state audit noted that the state’s reimbursement for the most common pediatric dental procedures are only 35% of the national average and that less than half (46%) of children enrolled in Medi-Cal received any dental service in the previous year. A little over half of all children and one-third of adults in the state are now Medi-Cal eligible, creating a dental service demand beyond the resources and capacity of the current Denti-Cal delivery system. A recent report by the Department of Health Care Services (DHCS) reported that the number of Denti-Cal providers has decreased 15% since 2008, while the number of beneficiaries has increased by 5 million in the same time period.
Little Hoover Commission Denti-Cal Study
The "Little Hoover Commission” on California State Government Organization and Economy is an independent state oversight agency created in 1962 to investigate state government operations and – through reports, recommendations and legislative proposals – promote efficiency, economy and improved service in state government. In April, Senator Dr. Richard Pan and Assembly Member Dr. Jim Wood petitioned the Commission to undertake a formal review of Denti-Cal program operations in the wake of the deficiencies outlined in the 2014 State Auditor’s Report (recounted above) and the lack of adequate response by the DHCS. The commission agreed to do so and held in September public hearing to initiate the study, at which CSPD provided invited oral testimony. I later spoke by telephone with the Deputy Executive Director and Staff to recommend focusing on three areas of accountability:
- Denti-Cal Beneficiary Utilization (patient access and services provided)
- Denti-Cal Provider Participation (network adequacy and capacity)
- Department of Health Care Services Denti-Cal oversight (responsibilities and execution)
The Commission will next likely assemble stakeholder focus groups to identify potential improvements to Detii-Cal operations to recommend to the Department and to the Legislature. The next open meeting is scheduled for November 19.
Sedation and General Anesthesia Authorization
In September the DHCS released a Denti-Cal Provider Bulletin outlining a revised policy, effective November 1, requiring providers of general anesthesia (D9220/D9221) and intravenous sedation (D9241/D9242) to submit a Treatment Authorization Request (TAR) prior to the delivery of care.
The Bulletin outlines Intravenous Sedation and General Anesthesia Guidelines, Criteria Indications, and Reimbursement Scenarios based on treatment location and anesthesiology provider (http://www.denti-cal.ca.gov/provsrvcs/bulletins/Volume_31_Number_13a.pdf). Additionally, the Bulletin provides guidance regarding the administration of oral conscious sedation (D9248). Previously, medical managed care organizations (MCOs) had been provided an All Plans Letter outlining essentially the same information.
The California Dental Association advocated extensively with the DHCS, in partnership with CSPD and the Oral and Facial Surgeons of California (and other stakeholders) over the course of a year on this important issue. Our focus has been, and continues to be, to ensure that Denti-Cal beneficiaries receive access to appropriate care using the proper sedation modality based on the clinical judgment of the treating dentist in conjunction with the informed consent of the patient (parent).
There remain critical issues related to the new policy that CSPD is attempting to address to ensure timely access to appropriate adjunctive services, including expanding the list of providers able to submit the authorization requests and ensuring medical plans (MCOs) do not construct unacceptable administrative barriers to care.
State Oral Health Plan
As reported earlier in this column, Dr. Jayanth (Jay) Kumar took office August 1 as the Dental Director of the new Office of Oral Health within the California Department of Public Health (CDPH). With his appointment, the initial steps to develop a State Oral Health Plan and an Oral Health Surveillance Plan were taken by the creation of a California Oral Health Program Advisory Committee. The State Oral Health Plan is intended to serve as a roadmap to identify priorities and objectives to address the burden of oral disease in the state, increase access to oral health services for high risk populations, and improve the oral health status of all Californians.
The Advisory Committee met for the first time in August to create an organizational structure and provide overall direction in regards to the development of the plan. CSPD was invited by Dr. Kumar and the CDPH to sit on the Advisory Committee, which met again in Sacramento in October. At that meeting, the key priorities of the plan were identified in three areas as follows:
- Access to Care
- Community-Based Prevention
- Communication and Education
In addition to developing the State Oral Health Plan, Dr. Kumar is charged with securing federal and other funding for oral health and prevention services, with children as the primary target of these programs.
Tobacco Tax Initiative
In the closing days of the 2015 legislative session, with active opposition from the tobacco lobby and a general impasse on managed care organization (MCO) tax reform and other special session issues, a package of tobacco-related bills failed to emerge for house votes. In response, the Save Lives California coalition filed a ballot measure for the November 2016 election to raise the state’s tobacco tax by $2.00 per pack. In addition to increased Medi-Cal reimbursement rates that the new revenue would provide, the measure would dedicate $30 million annually to fund State Oral Health Plan programs overseen by the State Dental Director. This would be an unprecedented dedicated funding source for oral health programs in California.
State Health Benefits Exchange
2015 marked the second year that the provisions of the Affordable Care Act regarding mandatory health coverage for most Americans ---- or pay a penalty --- were in effect. Pediatric dental services for children are one of the 10 Essential Health Benefits covered under the Act and California’s Health Benefits Exchange ----- Covered California ---- elected to provide these benefits exclusively in 2014 by the separate purchase of a stand-alone pediatric dental plan. As a result of the manner in which it was offered (as a voluntary add-on item after the purchase of the health plan was completed), the disappointing take-up rate was less than 30%. This year, the stand-alone pediatric dental plans were eliminated from the Exchange and, instead, all medical plans include embedded pediatric dental benefits. Medical plans partnered with dental plans to provide these embedded benefits, which have a separate deductible and a separate out-of-pocket maximum from those of the medical benefits. State regulators are required to separately monitor the adequacy of dental plan provider networks and timely access to dental care.
It is anticipated that stand-alone family dental plans will be offered in the state exchange and SHOP (Small Business Health Options Program) to adults wishing to obtain dental coverage in 2016. These plans will include dependent coverage and, when purchased, the child’s dental benefits under the plan will be secondary to the benefits of the embedded dental plan.