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The dental initiatives of California’s transformative Medi-Cal proposal, California Advancing and Innovating Medi-Cal (CalAIM), have been in effect since Jan. 1, 2022, and have added to the significant gains made by the Medi-Cal Dental Program, which is designed to serve more than 14.7 million eligible Californians.
Dentists who treat Medi-Cal members acquired new treatment options in 2022, including the ability to provide silver diamine fluoride as a benefit for eligible patients who include children under age 7, individuals living in a skilled nursing or care facility and persons with intellectual or developmental disabilities.
The expanded benefit comes after several years of CDA's advocacy to add SDF as a benefit and aligns with national dental care standards, underscoring the state’s commitment to regular preventive oral health visits for young children and those with complex health care needs.
The improvements made in 2022 add to those the state has made over the past several years, including increased provider rates for children and adult services, reduced administrative burdens and the ability for providers to enroll in the program and complete recertification online.
John Blake, DDS, executive director of The Children’s Dental Health Clinic in Long Beach, sees the improvements. “The fee enhancements and preventive treatment incentives over the past five years have helped not only our practice’s bottom line but, more importantly, our patients and their oral health,” he said. Over 95% of the clinic's patients are (FFS) Medi-Cal.
From 2017 to 2019, Medi-Cal Dental visits increased by 115,000 statewide, and nearly 100,000 additional preventive services were performed. An expected dip in utilization of services occurred in 2020, the first year of the COVID-19 pandemic, but utilization has begun to recover to pre-pandemic levels. Continue reading to learn how six major changes to Medi-Cal Dental are working for participating providers and patients.
For years, providers have complained of a long, burdensome paper enrollment process, but Medi-Cal enrollment is now simplified and accelerated for dental providers.
Providers will now submit their enrollment applications and documentation and complete their revalidation entirely online through the Provider Application and Validation for Enrollment (PAVE), launched Oct. 31 by the state Department of Health Care Services. In fact, DHCS is no longer accepting paper enrollment applications. Providers will also be able to track their application progress and access their accounts through the new online system.
Providers can visit the PAVE website to enroll, revalidate and learn more through recorded training videos and FAQ.
A new CalAIM initiative added the caries risk assessment bundle as a dental benefit in alignment with national dental care standards. The CRA bundle consists of either D0601, D0602 or D0603 (CRA exams at low, moderate and high risk) and D1310 (nutritional counseling). The overall goal of the new benefit is to assess and manage caries risk and to emphasize the provision of preventive services in lieu of more invasive and costly procedures for children ages 0-6.
Dr. Blake said many patients ages 0-6 seen by his clinic have moderate to high caries risk and called the bundle a “thoughtful and welcome bundle reimbursement from the program.”
“The discussions we have with our patients’ parents or caregivers are now incentivized and an integral part of improving and maintaining a healthy diet and healthy oral hygiene habits,” Blake added.
The benefit is available statewide and allows providers, including allied dental professionals, to bill for the CRA bundle rate including the allowable increased frequencies for certain preventive services for those with moderate and high caries risk. More information is available through the Medi-Cal Dental Manual of Criteria and the Medi-Cal Dental Provider Bulletin.
A change in the criteria of procedure code D9920, which is a dental code included in Proposition 56, the CDA-supported tobacco-tax increase that California voters passed in 2016, has been in effect since Oct. 15, 2018, and exclusively allows providers extended time to render dental services to patients with special health needs. Special-needs patients are individuals who have a physical, behavioral, developmental or emotional condition that prohibits them from adequately responding to a provider’s attempts to perform a dental visit.
D9920 is a benefit for up to four visits in a 12-month period to compensate the dental provider for additional time needed for providing services to patients with special health needs and only in conjunction with procedures that are payable.
When submitting claims for procedure D9920, DHCS notes that the documentation should include the medical diagnosis and reason why extra time is needed if the medical condition alone does not justify the need, e.g., quadriplegic. Providers should indicate the reason they are unable to render the procedure(s) to the patient within a reasonable amount of time with appropriate documentation consistent with the Medi-Cal Dental Manual of Criteria. D9920 is intended for situations that require extra time due to a particular medical condition and not for extra minutes to calm a patient or to review an extensive medical history, for example.
Because the hospital-based program run by Dr. Blake and his team treats a high number of patients with special mental and physical health care needs, Blake said the D9920 procedure code “has been helpful in recognizing, and helping pay for, the additional time and preparation needed to treat SHN patients. Thank you, DHCS.” Blake noted the importance of appropriate use and proper documentation of D9920.
D9920 will not be paid to providers if the behavior modification modality is sedation (oral, intravenous or nitrous oxide). More information is available through the Medi-Cal Dental Manual of Criteria and the Medi-Cal Dental Provider Bulletin.
The benefit criteria regarding crowns for adults ages 21 and over have been expanded to align standards of dental care with evidence-based practices. Adults 21 and over may receive specific laboratory-processed crowns on posterior teeth when medically necessary to restore a posterior tooth to normal function. More details on this new benefit can be found in the Medi-Cal Dental Manual of Criteria.
Medi-Cal members with special health care needs who are unable to schedule and coordinate complex treatment plans among multiple practitioners can get assistance through the Medi-Cal Dental Program. Examples of special health care needs include physical, developmental, mental, sensory, behavioral, cognitive or emotional impairment, or a limiting condition that requires medical management or health care intervention or the use of specialized services or programs.
The member's Medi-Cal Dental provider will initiate the referrals for case management services based on a current, comprehensive evaluation and treatment plan. All referrals will be evaluated to determine eligibility for case management and, if criteria are met, a case management representative will initiate contact with the member or member representative.
Medi-Cal Dental providers can refer patients to case management by completing the case management referral form and submitting it in a HIPAA-compliant manner.
CalHealthCares, overseen by DHCS, is designed to expand access to care by incentivizing dentists and physicians to serve Medi-Cal beneficiaries by repaying educational debt or covering eligible practice-related expenses.
Dentists who participate in the Medi-Cal program are eligible for student loan repayment up to $300,000 for a five-year service obligation or a practice support grant of up to $300,000 in exchange for a 10-year service commitment. The practice support grant can be used to establish, expand or relocate a practice in specific counties with the highest patient need for Medi-Cal dental services.
CalHealthCares launched in July 2019 and is funded by Proposition 56 — the state tobacco tax co-sponsored by CDA and passed by voters in 2016. Since its inception, CalHealthCares has awarded approximately $38 million in student loan repayment and practice support grants to 148 California dentists.
The next CalHealthCares application cycle (cohort 5) will open Jan. 18, 2023. CDA will share more details and reminders about the application window via the CDA Newsroom and weekly member newsletter. Dentists will apply online through the CalHealthCares website.
CDA has been at the center of the push to improve access to quality care within the Medi-Cal Dental Program and is pleased to see the state working to make Medi-Cal Dental a better program for patients and for dentists.
Over the last several years, the state fully restored adult dental benefits, substantially increased provider rates for both children and adult services through incentives, pilot projects and supplemental rates and significantly reduced administrative burdens, including through a streamlined provider enrollment process.
Learn more about Medi-Cal Dental through the DHCS providers page or read CDA’s extensive coverage about the program. You can also sign up to automatically receive the monthly Medi-Cal Dental Provider Bulletins and related communications by email.