Significant investment in state dental program

At the end of 2015, the state of California and the federal government reached an unprecedented agreement that will make an additional $740 million investment in California's Denti-Cal program over the next five years. California has often made changes to its contract with the federal Centers for Medicare and Medicaid Services (CMS), which governs the operation of the Medicaid program (Medi-Cal in California), with the goal to increase flexibility and funding for the medical services covered by the program. This, however, is the first time the state's neglected and underfunded dental program, Denti-Cal, has received this kind of attention and substantial investment.

CDA advocated strongly for the final plan to focus on the under-resourced Denti-Cal program and urged the state to develop a plan that implemented substantive, outcome-driven programmatic changes to help improve and increase access to care in the program. While the initial waiver guidelines stop short of offering a comprehensive program transformation, they deliver much needed fiscal incentives for preventive care, care to young children and continuity of care, allowing for some flexibility in the Denti-Cal program to better meet the needs of beneficiaries and testing some innovation at the local level, which are all elements CDA supported. 

As we work to implement the waiver and leverage this important opportunity, CDA will continue to advocate for comprehensive reform and targeted, ongoing rate increases, which are still desperately needed. Additional opportunities to improve the program this year include working to support the efforts of the state's Little Hoover Commission, an independent oversight committee that is exploring potential improvements to make the Denti-Cal program easier to use and more attractive and viable for providers. In addition, during this year's budget process CDA will be advocating for the Legislature to renew the state's managed care organization (MCO) tax, which supplies more than $1 billion in federal matching funds to the state's Medicaid program that will expire at the end of June if the state does not make changes to comply with federal requirements.   

Moving hand in hand with these ongoing opportunities, the federal waiver, officially known as the Medi-Cal 2020 Waiver, offers a new influx of funding and reform efforts to help address the problems in our Denti-Cal system. While there are many details of the "Dental Transformation Initiative" that need to be determined, there is a framework for the dental investments: incentives for early, preventive care; implementation of caries risk assessment and disease management pilots; bonus payments to providers for continuity of care; and a competitive grant program to fund local initiatives that address these three areas in innovative ways. 

Incentives for Early, Preventive Care
The state has set a goal to increase the number of children (0-20 years old) who receive a preventive dental service by 10 percentage points over the five-year waiver period. To achieve that goal, the state intends to provide additional payments to providers for prevention services, but only once a countywide utilization baseline has been achieved. The state wants to increase preventive care for patients while still maintaining care for children who previously received this service. Each Denti-Cal office location will have its unique utilization benchmark to achieve, and once reached, the state will provide semi-annual payments to providers for the prevention services they deliver. The amount of those incentive payments will be 75 percent above the current schedule of maximum allowance rates for all prevention services provided. While the state selected a rather complicated implementation methodology, this represents a considerable investment in preventive care and recognizes the need for substantial increases in the funding providers receive. 

Caries Risk Assessment and Disease Management Pilot Program
The state is seeking to pilot a caries risk-based treatment model, with the goal of emphasizing the provision of preventive services in lieu of more invasive and costly procedures. The state will provide authorization for additional services for children (0-6 years old) based on their level of risk using a caries risk assessment tool. Additional paid services can include exams, cleanings and fluoride varnishes. Funding for motivational interviewing/counseling and the use of antimicrobials is also included.    

The counties in which this pilot program will be offered have not yet been determined, though a focus will be on counties that currently have high treatment costs, a low percentage of prevention services and an indication of likely participation by dentists. Denti-Cal dentists who have been trained and certified by the Department of Health Care Services (DHCS) will be able to opt into this pilot program in selected counties. CDA was named in the waiver agreement as a likely partner in developing the training protocols.  This program will begin in 2017. 

Continuity of Care
This pilot program is designed to ensure patients age 0-20 years old who access care continue to seek the care they need on an ongoing basis. To that end, the state will provide 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 amount of the bonus payments has not yet been determined. 

Local Dental Pilot Program
Toward the end of the negotiation process with CMS, the state added a fourth component of the waiver funding – one dedicated to providing local entities with an opportunity to seek funding through a competitive bid process to design their own pilot programs. The programs must address one or more of the three domains already included in the waiver, using alternative program designs. DHCS has stated that it will require these pilots to have broad-based provider and community support and will work with CMS in the evaluation of proposed local pilots. A limit of 15 local pilots will be approved.

The addition of $740 million over five years represents a tremendous investment in the Denti-Cal program, but a great amount of work and implementation planning is still needed. Issues such as where pilot programs will be located, how best to incentivize provider participation, identification of appropriate CAMBRA training modules and how best to evaluate which local pilot proposals to implement are examples of issues CDA will continue to address. 

For more information, contact CDA's Director of Public Policy Nicette Short at nicette.short@cda.org or click on the Medi-Cal 2020 Wavier link on the state's website at www.dhcs.ca.gov.

Related Items

Covered California, California’s health insurance marketplace for the federal Affordable Care Act, is now offering family dental plans to purchase for the 2016 benefit year. The standalone family dental plans are available in addition to the children’s dental coverage included as an essential health benefit for consumers younger than 19 years old.