Report 2013-125 Recommendation 5 Responses

Report 2013-125: California Department of Health Care Services: Weaknesses in Its Medi-Cal Dental Program Limit Children's Access to Dental Care (Release Date: December 2014)

Recommendation #5 To: Health Care Services, Department of

To help increase the number of providers participating in the program's fee-for-service delivery system, Health Care Services should improve its identification and implementation of changes that minimize or simplify administrative processes for providers. These changes should include revising its processes pertaining to dental procedures that require radiographs or photographs.

Annual Follow-Up Agency Response From November 2020

DHCS implemented CDT 16 through CDT 19 code updates in March and May 2020, respectively, and released a provider bulletin article notifying providers of the changes. The dental Manual of Criteria and Schedule of Maximum Allowances with the code updates were implemented through bulletin authority and published on the Medi Cal Dental Website.

California State Auditor's Assessment of Annual Follow-Up Status: Fully Implemented

Annual Follow-Up Agency Response From October 2019

DHCS has begun various phases of implementation for CDT 16; however, in an attempt to bring DHCS as current as possible with dental code sets, DHCS decided to bring it current through CDT 19. The complete update is on schedule for March 2020.

Proposition 56 supplemental payments have been implemented since FY 2017-18 and has been approved to continue through December 31, 2021. The supplemental payments vary between 20 to 60 percent of the Schedule of Maximum Allowances or a specific dollar increase effective July 1, 2018, through June 30, 2019.

California State Auditor's Assessment of Annual Follow-Up Status: Pending

Annual Follow-Up Agency Response From November 2018

CDT 2016 implementation date has moved from the anticipated January 2018 to approximately December 31, 2018 due to extensive system changes necessary to implement the CDT updates.

MDSD issued multiple provider bulletins in 2017 and in 2018 regarding implementation of Proposition 56 supplemental payments. Proposition 56 dental page also notes the SPA approval for 2017 and 2018: https://www.dhcs.ca.gov/services/Pages/Proposition-56-Dental.aspx

California State Auditor's Assessment of Annual Follow-Up Status: Pending

Annual Follow-Up Agency Response From September 2017

This recommendation has been implemented by the administrative simplifications noted in prior updates and our ongoing efforts noted in this update. On January 1, 2017 DHCS implemented a new Denti-Cal Provider Enrollment Application, consolidated the Medi Cal Dental provider application and enrollment process, and reduced the number of forms from four to one. Providers will no longer download multiple forms and sign multiple times to add a practice and accept beneficiaries. With the implementation of AB 2207, a provider application won't be returned for missing information if it is provided elsewhere in the application packet. DHCS will use the bulletin authority provided from AB 2207 to update the current CDT 2013 regulatory package to CDT 2016, inclusive of administrative simplifications to reduce the amount of paperwork on providers for submitting Treatment Authorization Requests and claims. DHCS intends to submit and implement this regulatory package in January 2018 to account for the restoration of adult benefits. DHCS is implementing initiatives to influence provider participation through supplemental payments to providers on specific procedures utilizing funding from Proposition 56 in accordance with AB 120. These funds are in addition to the current Dental Schedule of Maximum Allowances (SMA) and will be at a payment rate equal to 40 percent of the SMA for the specified codes for dates of service during July 1, 2017 through June 30, 2018. Upon federal approval, effective January 1, 2018, DHCS will restore adult dental benefits previously eliminated from the 2009 SPA, resulting in full-scope adult dental benefits.

California State Auditor's Assessment of Annual Follow-Up Status: Partially Implemented

We cannot confirm that DHCS has fully implemented this recommendation. Although we obtained documentation that DHCS streamlined the application and process to become a Medi-Cal dental provider, it did not provide documents related to its implementation of CDT 2016 or its implementation of supplemental payments to Medi-Cal dentists for certain procedures.

Annual Follow-Up Agency Response From November 2016

In conjunction with Denti-Cal stakeholders, DHCS implemented administrative simplifications into the dental program such as payment for restorations not requiring radiograph submission unless selected for random sampling, eliminated the prior authorization requirement for immediate dentures (where there are teeth that need extraction); and added clarifying language and materials to assist in the prior authorization requirement for general anesthesia/intravenous sedation. Additionally, effective July 1, 2015, enrolled Denti-Cal billing providers are permitted to use Teledentistry as an alternative modality for the provision of dental services via store and forward. Teledentistry live transmission services are pending final CMS SPA approval which is anticipated to be secured by December 2016. In addition, DHCS is consolidating the proposed set of Current Dental Terminology code additions and anticipates a regulation package will be submitted formally for a public comment period and review with the Office of Administrative Law anticipated in the second quarter of 2017. As noted earlier, DHCS provided extensive technical assistance to the author's office on the provisions contained in AB 2207. In terms of simplifications, AB 2207 grants DHCS the ability to utilize all plan letters, provider bulletins, or the like to implement, interpret, and make specific policies and procedures for the DMC and FFS delivery systems until regulations are adopted; however, utilization of these notification processes will require DHCS to provide a status report to the legislature on a semiannual basis until such regulations have been adopted. This will help DHCS to increase the number of providers participating in the Medi-Cal Dental Program fee-for-service delivery system by ensuring quicker identification and implementation of changes that minimize or simplify administrative processes for providers.

California State Auditor's Assessment of Annual Follow-Up Status: Not Fully Implemented

1-Year Agency Response

DHCS has proposed a set of Current Dental Terminology code additions which are currently in the internal review process and will be submitted formally to the Office of Administrative Law early in 2016. Additionally administrative simplifications will be incorporated into the dental program such as payment for restorations not requiring radiograph submission unless selected for random review; prior authorization not required for immediate dentures (where there are teeth that need extraction); and a prior authorization requirement for general anesthesia/intravenous sedation. Teledentistry is a recently offered modality and live transmission services will prospectively be reimbursable. In addition, pursuant to the special terms and conditions under the Medi-Cal 2020 waiver for the dental component, incentives will also be offered to select providers through an incentive program pilot to perform caries risk assessments, motivational interviewing, and other preventive care.

California State Auditor's Assessment of 1-Year Status: Pending

6-Month Agency Response

DHCS is in the process of re-evaluating existing policies and simplifying administrative processes to encourage provider participation. DHCS has established regular meetings with dental consultants to re-evaluate existing policies with the objective to implement administrative simplifications while upholding program integrity and adhering to medical necessity criteria which is federally required and designed to protect and ensure the health and well-being of Medi-Cal beneficiaries. Current policy requires that any administrative simplification(s) must be implemented through the regulatory process which can take anywhere from one to two years. An alternate means to expedite implementation of recommended simplifications would require a statute change. Implementation must therefore be changed to no earlier than July 1, 2016.

California State Auditor's Assessment of 6-Month Status: Pending

60-Day Agency Response

DHCS is in the process of re-evaluating existing policies and simplifying administrative processes to encourage provider participation. With the implementation of new Current Dental Terminology (CDT) codes issued by the American Dental Association for 2015, DHCS will identify opportunities to offer providers a simplified process in their claims submission. DHCS has established regular meetings with program and contractor dental consultants to re-evaluate existing policies whose main objective is to implement administrative simplifications while upholding program integrity and adhering to medical necessity criteria which are designed to protect and ensure the health and well-being of Medi-Cal beneficiaries. DHCS intends to meet its established implementation date of July 1, 2015.

California State Auditor's Assessment of 60-Day Status: Pending

All Recommendations in 2013-125

Agency responses received are posted verbatim.