Not your father’s Medi-Cal

Program changes promote preventive dental care, tobacco cessation
October 21, 2019

Improvements to the Medi-Cal Dental program continue with new options for dentists who treat Medi-Cal members, including the ability to provide fluoride treatment and fluoride varnish as a benefit once every four months for patients under age 6. The increase in the benefit periodicity underscores the state’s commitment to regular preventive oral health visits for young children in California.

Dentists can also now receive reimbursement for tobacco cessation counseling and can initiate referrals for case management for their patients’ complex health care needs. Both options will help dentists better serve their Medi-Cal patients and receive reimbursements that support the provision of care.

The improvements add to those the state has made over the past five years, including fully restored adult benefits, increased provider rates for children and adult services and reduced administrative burdens.

Dentists have noticed the changes.

Rick Nichols, DDS, has been providing care to children in the Denti-Cal program for 25 years. The pediatric dentist said the program is “very different today” than it was in the past.

“I am as busy as I wish to be, and with the changes in the fee schedules and the implementation of the incentive plan the state created, I feel I am adequately reimbursed for the care I provide,” said Dr. Nichols, who practices in Redlands.

“If you dropped out or have stayed away, now is the time to reconsider being a provider,” Nichols said. “The kids need us.”

Read on for details about the latest program improvements.

Fluoride periodicity increase for young children

In a May Provider Bulletin, the Department of Health Care Services announced a change in the benefit periodicity for fluoride treatment (D1206) and fluoride varnish (D1208) for children under age 6. It was increased from once every six months to once every four months to be consistent with clinical guidelines for prevention in this age group and to align the program policies with the American Academy of Pediatric Dentistry’s guidelines.

Tobacco cessation counseling

Similarly, dentists can now receive reimbursement for tobacco counseling (D1320), which highlights the important role dental professionals play in identifying nicotine use and promoting smoking cessation. CDA has a long history of supporting efforts to reduce tobacco use in California, most recently through successful advocacy to increase the state’s tobacco tax through Proposition 56 in 2016. Documentation in the patient record of a face-to-face encounter must include the following five A’s of tobacco dependence counseling:

  • Ask the patient about tobacco use at every visit and document the response.
  • Advise the patient to quit in a clear and personalized manner.
  • Assess the patient’s willingness to make a quit attempt at this time.
  • Assist the patient to set a quit date and make a quit plan.
  • Arrange to follow up with the patient within the first week, either in person or by phone, and take appropriate action to assist them.

If the patient is unwilling to quit, the provider should document the patient’s expressed barriers.

For procedure code D1320, a new schedule of maximum allowances not to exceed $10/billable visit will be added, effective for dates of service on and after June 1, 2019. See Provider Bulletin volume 35, number 15 for more information.

Behavior management for patients

As part of Proposition 56, a criteria change to procedure code D9920 is now in effect and exclusively provides extended time to render dental services to special-needs patients. Special-needs patients are those patients 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 special-needs patients and only in conjunction with procedures that are payable.

DHCS notes that when submitting claims for procedure D9920, 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. D9920 is intended for situations that require extra time due to a particular medical condition and not for extra minutes to calm a patient down or to review an extensive medical history, etc. D9920 will not be paid to providers if the behavior modification modality is sedation.

Lab-processed crowns for children

Both anterior and posterior endodontically treated teeth for children under age 21 are eligible for laboratory-processed crowns, as a June 2019 Provider Bulletin clarified. The benefit criteria for crowns for adults 21 and over has not changed.

Case management for complex health care needs

The Medi-Cal Dental Program recently launched a case management option to assist Medi-Cal members with special health care needs who are unable to schedule and coordinate complex treatment plans among multiple practitioners. Examples of special health care needs include physical, developmental, mental, sensory, behavioral, cognitive or emotional impairment or a limiting condition that requires medical management, 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 to be 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 referral form and submitting it in a manner that is compliant with HIPAA.

To download and submit a case management referral form, go to the Provider Forms page.

Update to CDT-19 code set coming spring 2020

DHCS announced in a September Bulletin that the Medi-Cal Dental Program has been working diligently to update the program from the American Dental Association’s Current Dental Terminology code set (CDT-13) to CDT-19. The update is scheduled to implement in spring 2020, and more information will be available as the release date nears.

Building on five years of improvements

Over the past five years, the state fully restored adult dental benefits and significantly increased provider rates for both children and adult services through incentives, pilot projects and supplemental rates — in some cases approaching 75% or more of usual and customary rates. Administrative burdens were reduced and a streamlined provider enrollment process was implemented.

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.

Learn more about Medi-Cal Dental through the providers page or read CDA’s extensive coverage about the program. You can also sign up to automatically receive the monthly Denti-Cal Bulletin and related communications by email.


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