Opportunities for dentists serving low-income children

Dentists in California now have an opportunity to participate in the Dental Transformation Initiative to help improve dental health for low-income children enrolled in the Denti-Cal program, while receiving enhanced reimbursement by meeting specific incentive metrics. As part of California's 1115 waiver, known as Medi-Cal 2020, the DTI focuses on high-value care, improved access and utilization of performance measures to drive delivery system reform.

CDA strongly advocated that oral health services be included in the waiver agreed upon late last year by the state of California and the Centers for Medicare and Medicaid Services. The unprecedented agreement offers increased state flexibility to meet the needs of its 13.5 million beneficiaries and infuses an additional $740 million investment in Denti-Cal over the next five years.

There are four domains under DTI. Two of the four domains are already underway — Domain 1 and Domain 3.

Incentives for early, preventive care: Domain 1

The state has set a goal to increase the number of children (0-20 years old) who receive preventive dental services by 10 percent over the five-year waiver period. Under Domain 1, the program provides significant bonus payments to providers who are able to increase the number of Denti-Cal beneficiaries they serve by 2 percent per year.

Each participating Denti-Cal office location will have a unique utilization benchmark to achieve, and the state will provide semiannual payments to providers for the prevention services they deliver to new patients above their benchmark. Incentive payments will be 75 percent above the current schedule of maximum allowance (SMA) for all prevention services provided to the new patients. This represents a considerable investment in preventive care and recognizes the need for substantial increases in the funding providers receive.

Domain 1 incentives payments are available to Denti-Cal-enrolled dentists statewide. The pilot officially began on July 1, 2016. The Department of Health Care Services will soon mail letters notifying providers of their benchmark number of patients and goal required to achieve incentive payments. This benchmark is calculated based on the service office location's delivery of preventive services to Medi-Cal beneficiaries' data during the baseline calendar year 2014. Newly enrolled providers will be subject to the state's predetermined benchmark based on their county.

Any dentist already enrolled in Denti-Cal is eligible for these incentive payments without any further action. DHCS will issue the first incentive payments in January 2017 to those provider locations that met or exceeded the goal of a two-percentage point increase of Denti-Cal patients from the first six months of the program. Providers who wish to enroll as a Denti-Cal provider and participate in this domain may do so at any time.

Continuity of care: Domain 3

This domain is designed to ensure Denti-Cal children ages 20 and under continue to receive the dental care they need on an ongoing basis by providing incentive payments to dental service office locations who have maintained continuity of care through the provision of recall exams for their Denti-Cal patients.

The incentive will be paid as an annual bonus payment to providers for each child who receives a dental exam for two consecutive years at the same dental office. The per-child bonus increases in each subsequent year if treatment continues to be provided at the same treatment location. The first annual bonus payment (after the second year of consecutive treatment) will start at $40 per Denti-Cal beneficiary, increasing by $10 each year up to $90 after five years of consecutive recall visits for the same patient.

Since Domain 3 is a pilot, only dentists in the selected pilot counties are eligible to participate in Domain 3. The selected pilot counties are Alameda, Del Norte, El Dorado, Fresno, Kern, Madera, Marin, Modoc, Nevada, Placer, Riverside, San Luis Obispo, Santa Cruz, Sonoma, Shasta, Stanislaus and Yolo.

For more specifics regarding the Dental Transformation Initiative, visit the DTI page on the DHCS website.

Related Items

The California Department of Public Health’s Nutrition Education and Obesity Prevention Branch is recruiting the next cohort of "champion providers" to help support local health departments’ efforts to improve the health of communities by advancing local policy, systems and environmental change strategies. The department contacted CDA to express the importance of engaging dentists in this endeavor.

The 2017 open enrollment period for Covered California, California’s health insurance marketplace for the federal Affordable Care Act, continues through Jan. 31. CDA reported in September on the partial list of participating dental plans for 2017. The complete list of providers, along with the 2017 embedded children’s dental plans, has now been released.

Beginning in January 2017, dentists in select California counties will have an opportunity to participate in an innovative pilot that seeks to assess and manage caries risk and emphasize the provision of preventive services to Denti-Cal-enrolled children ages 6 and under.