Bill Text: CA AB2207 | 2015-2016 | Regular Session | Amended
NOTE: There are more recent revisions of this legislation. Read Latest Draft
Bill Title: Medi-Cal: dental program.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Passed) 2016-09-25 - Chaptered by Secretary of State - Chapter 613, Statutes of 2016. [AB2207 Detail]
Download: California-2015-AB2207-Amended.html
Bill Title: Medi-Cal: dental program.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Passed) 2016-09-25 - Chaptered by Secretary of State - Chapter 613, Statutes of 2016. [AB2207 Detail]
Download: California-2015-AB2207-Amended.html
BILL NUMBER: AB 2207 AMENDED
BILL TEXT
AMENDED IN SENATE AUGUST 15, 2016
AMENDED IN SENATE JUNE 28, 2016
AMENDED IN SENATE JUNE 9, 2016
AMENDED IN ASSEMBLY APRIL 26, 2016
INTRODUCED BY Assembly Member Wood
FEBRUARY 18, 2016
An act to amend Sections 14132.915 and 14459.6 of, to add Sections
14184.72, 14184.73, 14184.74, and 14184.75 to, and to add Article
4.10 (commencing with Section 14149.8) to Chapter 7 of Part 3 of
Division 9 of, the Welfare and Institutions Code, relating to
Medi-Cal.
LEGISLATIVE COUNSEL'S DIGEST
AB 2207, as amended, Wood. Medi-Cal: dental program.
Existing law provides for the Medi-Cal program, which is
administered by the State Department of Health Care Services and
under which qualified low-income persons receive health care
benefits. The Medi-Cal program is, in part, governed and funded by
federal Medicaid program provisions. Existing law provides that
certain optional benefits, including, among others, certain adult
dental services, are excluded from coverage under the Medi-Cal
program. Existing law, beginning May 1, 2014, or the effective date
of any necessary federal approvals, whichever is later, provides that
only specified adult dental services are a covered Medi-Cal benefit
for persons 21 years of age or older.
This bill would require the department to undertake specified
activities for the purpose of improving the Medi-Cal Dental Program,
such as expediting provider enrollment and monitoring dental service
access and utilization. The bill would require a Medi-Cal managed
care health plan to provide dental health screenings for eligible
beneficiaries and refer them to appropriate Medi-Cal dental
providers. This bill would provide that those provisions shall only
be implemented to the extent that the department obtains any
necessary federal approvals and federal matching funds.
Existing law requires the department to establish a list of
performance measures to ensure the dental fee-for-service program
meets quality and access criteria required by the department.
Existing law requires the department to annually post on October 1
the list of performance measures and data of the dental
fee-for-service program for the previous calendar year on its
Internet Web site. Existing law also requires the department to
establish a list of performance measures to ensure dental health
plans meet quality criteria required by the department. Existing law
requires the department to post, on a quarterly basis, the list of
performance measures and each plan's performance on the department's
Internet Web site.
This bill would add performance measures to the lists for both the
dental fee-for-service program and dental plans described above, as
specified. The bill would, as of October 31, 2016, eliminate the
requirement that the department annually post the performance
measures and program data relating to the dental fee-for-service
program for the previous calendar year on October 1 and instead would
require the department, commencing January 31, 2017, to post that
information for the previous fiscal year on its Internet Web site on
or before January 31 of each year. The bill, commencing April 30,
2017, and on specified dates thereafter, would require the department
to post dental fee-for-service program performance data, the dental
health plan performance measures, and each dental health plan's
performance on a quarterly basis for the preceding fiscal quarter on
its Internet Web site. The bill would require the department to
ensure, to the greatest degree possible, that the categories of data
and performance measures selected for the dental fee-for-service
program and for dental health plans are consistent with one another.
The bill would require the department, no sooner than July 1,
2019, to annually publish specified utilization data for both the
dental fee-for-service and dental managed care programs
from the preceding calendar year and to make this information
available on its Internet Web site.
SB 815 of the 2015-16 Regular Session, if enacted, would establish
Existing law establishes the Medi-Cal 2020
Demonstration Project Act, under which the department is required to
implement specified components of a Medicaid 1115(a) demonstration
project, referred to as California's Medi-Cal 2020 demonstration
project, consistent with the Special Terms and Conditions approved by
the federal Centers for Medicare and Medicaid Services (CMS).
AB 1568 of the 2015-16 Regular Session, if enacted, would
require Existing law requires the department to
implement the Dental Transformation Initiative (DTI), a component of
the Medi-Cal 2020 demonstration project, under which DTI incentive
payments, as defined, within specified domain categories would be
made available to qualified providers who meet achievements within
one or more of the project domains, and would require the department
to evaluate the DTI as required under the Special Terms and
Conditions.
This bill would require, consistent with the Special Terms and
Conditions and the evaluation requirement described above, the
department's reports of data and quality measures submitted to CMS
and made publicly available for each of the domain areas under the
DTI to include specified information.
Vote: majority. Appropriation: no. Fiscal committee: yes.
State-mandated local program: no.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. Section 14132.915 of the Welfare and Institutions Code
is amended to read:
14132.915. (a) (1) The department shall establish a list of
performance measures to ensure the dental fee-for-service program
meets quality and access criteria required by the department. The
performance measures shall be designed to evaluate utilization,
access, availability, and effectiveness of preventive care and
treatment.
(2) Prior to establishing the quality and access criteria
described in paragraph (1), the department shall consult with
stakeholders, including representatives from counties, local dental
societies, nonprofit entities, legal aid entities, and other
interested parties.
(3) The performance measures established by the department to
monitor the dental fee-for-service program for children shall
include, but not be limited to, all of the following:
(A) Overall utilization of dental services.
(B) For each provider, all of the following:
(i) Number of annual dental visits.
(ii) Number of patients seen during the calendar year.
(iii)
(ii) Number of annual preventive dental services.
(iv)
(iii) Number of annual dental treatment services.
(v)
(iv) Number of annual examinations and oral health
evaluations.
(C) Number of applications of dental sealants and fluoride
varnishes.
(D) Continuity of care and overall utilization over an extended
period of time.
(E) All of the following ratios:
(i) Sealant to restoration.
(ii) Filling to preventive services.
(iii) Treatment to caries prevention.
(F) Number No sooner than January 1, 2018,
number of beneficiaries requiring general anesthesia to
perform procedures.
(4) The performance measures established by the department to
monitor the dental fee-for-service program for adults shall include,
but not be limited to, all of the following:
(A) Overall utilization of dental services.
(B) For each provider, all of the following:
(i) Number of annual dental visits.
(ii) Number of patients seen during the calendar year.
(iii)
( ii) Number of annual preventive dental
services.
(iv)
(iii) Number of annual dental treatment services.
(v)
(iv) Number of annual examinations and oral health
evaluations.
(C) Treatment to caries prevention ratio.
(5) The performance measures shall be reported as aggregate
numbers and as percentages, if appropriate, using standards that are
as equivalent to those used by managed care entities as feasible.
Performance measures for the dental fee-for-service program for
children shall be reported by age groupings if appropriate.
(b) The department shall include the initial list of performance
measures in any dental contract entered into between the department
and a fee-for-service contractor on or after enactment of this
section.
(c) To ensure that the dental health needs of Medi-Cal
beneficiaries are met, the department shall, when evaluating
performance measures for retention on, addition to, or deletion from,
the list of performance measures, consider all of the following
criteria:
(1) Annual and multiyear Medi-Cal dental fee-for-service trended
data.
(2) Other state and national dental program performance and
quality measures.
(3) Other state and national performance ratings.
(d) On October 1, 2014, for the 2013 calendar year, and on or
before October 1, 2016, for the 2015 calendar year, the list of
performance measures established by the department along with the
data of the dental fee-for-service program performance shall be
posted on the department's Internet Web site.
(e) Commencing January 31, 2017, for the 2015-16 fiscal year, and
annually on or before January 31 for each preceding fiscal year
thereafter, the list of performance measures established by the
department along with the data of the dental fee-for-service program
shall be posted on the department's Internet Web site.
(f) Commencing April 30, 2017, for the July 2016 to September
2016, inclusive, fiscal quarter, and quarterly thereafter on or
before April 30, July 31, October 31, and January 31 for the fiscal
quarter ending seven months prior, the data of the dental
fee-for-service program performance shall be posted on the department'
s Internet Web site.
(g) The department may amend or remove performance measures and
establish additional performance measures in accordance with all of
the following:
(1) The department shall consider performance measures established
by other states, the federal government, and national organizations
developing dental program performance and quality measures.
(2) The department shall notify a fee-for-service contractor, at
least 30 days prior to the implementation date, of any updates or
changes to performance measures. The department shall also post these
updates or changes on its Internet Web site at least 30 days prior
to implementation in order to maintain transparency to the public.
(3) In establishing the performance measures, the department shall
consult with stakeholders, including representatives from counties,
local dental societies, nonprofit entities, legal aid entities, and
other interested parties.
(h) The department shall annually prepare a summary report of the
nature and types of complaints and grievances regarding access to,
and quality of, dental services, including the outcome. Commencing
January 31, 2017, for the prior fiscal year, and annually thereafter,
for each preceding fiscal year, this report shall be posted on the
department's Internet Web site.
(i) The department shall ensure, to the greatest degree possible,
that the categories of data and performance measures selected under
this section are consistent with the categories of data and
performance measures selected under Section 14459.6.
(j) No sooner than July 1, 2019, the department shall annually
publish utilization data from the preceding calendar year and post
this material on its Internet Web site. The utilization data shall be
made publicly available for both the dental fee-for-service and
dental managed care programs. The utilization data shall include all
of the following information:
(1) Number of patients seen on a per-provider basis.
(2) Number of annual preventative dental services, dental
treatment services, examinations, and oral health evaluations
rendered by each provider during each calendar year.
(3) Number of beneficiaries who received general anesthesia
services.
SEC. 2. Article 4.10 (commencing with Section 14149.8) is added to
Chapter 7 of Part 3 of Division 9 of the Welfare and Institutions
Code, to read:
Article 4.10. Medi-Cal Dental Program
14149.8. (a) The department shall expedite the enrollment of
Medi-Cal dental providers by streamlining the Medi-Cal provider
enrollment process. The department shall pursue and implement all of
the following activities, to the extent permitted by federal law:
(1) Create a dental-specific enrollment form.
(2) Pursue an alternative automatic enrollment process for a
provider already commercially credentialed by either a dental
fee-for-service contractor or an administrative services contractor
for the purpose of providing services as a commercial provider.
(3) Discontinue requiring providers to resubmit an enrollment
application that has been deemed incomplete if the missing
information is available elsewhere within the application packet.
(4) To the extent that the department expedites the enrollment of
Medi-Cal dental providers by streamlining the Medi-Cal provider
enrollment process, the department shall publish the criteria for
those processes in applicable provider bulletins and manuals.
(b) (1) The department shall continuously
maintain the provider network by disenrolling
on a monthly basis by deactivating a billing and
rendering provider who has not, over a continuous 12-month
period, submitted a claim for reimbursement for services rendered.
(2) Prior to disenrolling deactivating
a provider described in paragraph (1), the department shall
send a notice to the provider informing the provider that
the provider shall be disenrolled deactivated
from the dental program unless the provider requests
reactivation within six months after the date of the notice.
The department shall not disenroll a provider pursuant to
paragraph (1) until six months after the date of that
notice. This paragraph shall not be implemented until the date
the department implements and programs the necessary system changes
to the California Dental Medicaid Management Information Systems to
implement this paragraph, or no sooner than July 1, 2017, whichever
is later.
(3) In order to improve the quality of the dental provider
network, the department also shall exercise additional measures as
appropriate and permitted by law, including, but not limited to,
temporary suspensions. The parameters and criteria developed by the
department for additional measures for deactivations and
disenrollments shall be published in applicable provider bulletins
and manuals.
(c) (1) The department shall monitor access and utilization of
Medi-Cal dental services in the fee-for-service and managed care
delivery systems to assess opportunities to improve access and
utilization, including an annual review of the treatment
authorization review process.
(2) The department shall assess opportunities to develop and
implement innovative payment reform proposals within the Medi-Cal
dental programs.
(d) The department shall explore additional opportunities to
improve the Medi-Cal Dental Program, in consultation with
stakeholders and as deemed appropriate by the department and to the
extent permitted by federal law, including, but not limited to, the
following:
(1) Aligning the provision of dental anesthesia services with that
of medical anesthesia services, including the ability to bill for
applicable facility fees and ancillary services.
(2) Adjusting other utilization controls for specialty services,
as appropriate, to promote access to care while still protecting
program integrity.
(3) Expanding the scope of beneficiary outreach activities
required by an entity that is contracted with the department to more
broadly address underutilization throughout the state.
(e) Prior to implementing an action pursuant to subdivision (d),
the department shall post the proposed action on its Internet Web
site at least 30 days before implementation.
(f) The department shall work with dental managed care plans that
contract with the department for the purposes of implementing the
Medi-Cal Dental Program, which includes, but is not limited to,
contracts authorized pursuant to Sections 14087.46, 14089, and
14104.3, to provide beneficiaries with access to dental plan liaisons
to assist in the coordination of care for enrolled members.
(g) A Medi-Cal managed care health plan shall do all of the
following:
(1) Provide dental screenings for every eligible beneficiary as a
part of the beneficiary's initial health assessment.
(2) Ensure that an eligible beneficiary is referred to an
appropriate Medi-Cal dental provider.
(3) Identify plan liaisons available to dental managed care
contractors and dental fee-for-service contractors to assist with
referrals to health plan covered services.
(h) (1) To increase the efficiency and timeliness of changes, any
contract amendment, modification, or change order to any contract
entered into by the department for the purposes of implementing the
state Medi-Cal Dental Program shall be exempt, except as provided in
paragraph (2), from Part 2 (commencing with Section 10100) of
Division 2 of the Public Contract Code, as well as Sections 11545 and
11546 of the Government Code, in addition to any policies,
procedures, or regulations authorized by those provisions.
(2) Paragraph (1) shall not exempt the department from
establishing a competitive bid process for awarding new contracts
pursuant to Section 14104.3, as well as for awarding new dental
contracts pursuant to Sections 14087.46 and 14089.
(i) Prior to implementing any change pursuant to this section, the
department shall consult with, and provide notification to,
stakeholders, including representatives from counties, local dental
societies, nonprofit entities, legal aid entities, and other
interested parties.
(j) (1) Notwithstanding Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code, the
department, without taking any further regulatory action, shall
implement, interpret, or make specific policies and procedures
pertaining to the dental fee-for-service program and dental managed
care plans, as well as applicable federal waivers and state plan
amendments, including the provisions set forth in this section, by
means of all-county letters, plan letters, plan or provider
bulletins, or similar instructions until regulations are adopted.
(2) No later than December 31, 2018, the department shall adopt
regulations in accordance with the requirements of Chapter 3.5
(commencing with Section 11340) of Part 1 of Division 3 of Title 2 of
the Government Code. Beginning six months after the effective date
of this section, and notwithstanding Section 10231.5 of the
Government Code, the department shall provide a status report to the
Legislature on a semiannual basis until regulations have been
adopted.
(k) This section shall be implemented only to the extent that all
of the following occur:
(1) The department obtains any federal approvals necessary to
implement this section.
(2) The department obtains federal matching funds to the extent
permitted by federal law.
SEC. 3. Section 14459.6 of the Welfare and
Institutions Code is amended to read:
14459.6. (a) The department shall establish a list of performance
measures to ensure dental health plans meet quality criteria
required by the department. The list shall specify the benchmarks
used by the department to determine whether and the extent to which a
dental health plan meets each performance measure. Commencing
January 1, 2013, and quarterly thereafter, the list of performance
measures established by the department along with each plan's
performance shall be posted on the department's Internet Web site.
The Department of Managed Health Care and the advisory committee
established pursuant to Section 14089.08 shall have access to all
performance measures and benchmarks used by the department as
described in this section.
(1) Commencing April 30, 2017, the quarterly reporting required by
this subdivision shall be posted in the following manner:
(A) On or before April 30, 2017, the reporting shall be posted for
the July 2016 to September 2016, inclusive, fiscal quarter.
(B) After April 30, 2017, the reporting shall be posted on a
quarterly basis on or before April 30, July 31, October 31, and
January 31 for the fiscal quarter ending seven months prior.
(2) The performance measures established by the department shall
include, but not be limited to, all of the following: provider
network adequacy, overall utilization of dental services, annual
dental visits, the total number of patients seen on a per-provider
basis and the total number of dental services rendered by each
provider during each calendar year, use of preventive dental
services, use of dental treatment services, use of examinations and
oral health evaluations, sealant to restoration ratio, filling to
preventive services ratio, treatment to caries prevention ratio, use
of dental sealants, use of diagnostic services, use of general
anesthesia for dental services, and survey of member satisfaction
with plans and providers.
(3) The survey of member satisfaction with plans and providers
shall be the same dental version of the Consumer Assessment of
Healthcare Providers and Systems (CAHPS) survey as used by the
Healthy Families Program.
(4) The department shall notify dental health plans at least 30
days prior to the implementation date of these performance measures.
(5) The department shall include the initial list of performance
measures and benchmarks in any dental health contracts entered into
between the department and a dental health plan pursuant to Section
14204.
(6) The department shall update performance measures and
benchmarks and establish additional performance measures and
benchmarks in accordance with all of the following:
(A) The department shall consider performance measures and
benchmarks established by other states, the federal government, and
national organizations developing dental program performance and
quality measures.
(B) The department shall notify dental health plans at least 30
days prior to the implementation date of updates or changes to
performance measures and benchmarks. The department shall also post
these updates or changes on its Internet Web site at least 30 days
prior to implementation in order to provide transparency to the
public.
(C) To ensure that the dental health needs of Medi-Cal
beneficiaries are met, the department shall, when evaluating
performance measures and benchmarks for retention on, addition to, or
deletion from the list, consider all of the following criteria:
(i) Monthly, quarterly, annual, and multiyear Medi-Cal dental
managed care trended data.
(ii) County and statewide Medi-Cal dental fee-for-service
performance and quality ratings.
(iii) Other state and national dental program performance and
quality measures.
(iv) Other state and national performance ratings.
(b) In establishing and updating the performance measures and
benchmarks, the department shall consult the advisory committee
established pursuant to Section 14089.08, as well as dental health
plan representatives and other stakeholders, including
representatives from counties, local dental societies, nonprofit
entities, legal aid entities, and other interested parties.
(c) In evaluating a dental health plan's ability to meet the
criteria established through the performance measures and benchmarks,
the department shall select specific performance measures from those
established by the department in subdivision (a) as the basis for
establishing financial or other incentives or disincentives,
including, but not limited to, bonuses, payment withholds, and
adjustments to beneficiary assignment to plan algorithms. These
incentives and disincentives shall be included in the dental health
plan contracts.
(d) (1) The department shall designate an external quality review
organization (EQRO) that shall conduct external quality reviews for
any dental health plan contracting with the department pursuant to
Section 14204.
(2) As determined by the department, but at least annually, dental
health plans shall arrange for an external quality of care review
with the EQRO designated by the department that evaluates the dental
health plan's performance in meeting the performance measures
established in this section. Dental health plans shall cooperate with
and assist the EQRO in this review. The Department of Managed Health
Care shall have direct access to all external quality of care review
information upon request to the department.
(3) An external quality of care review shall include, but not be
limited to, all of the following: performance on the selected
performance measures and benchmarks established and updated by the
department, the CAHPS member or consumer satisfaction survey
referenced in paragraph (2) of subdivision (a), reporting systems,
and methodologies for calculating performance measures. An external
quality of care review that includes all of the above components
shall be paid for by the dental health plan and posted online
annually, or at any other frequency specified by the department, on
the department's Internet Web site.
(e) All marketing methods and activities to be used by dental
plans shall comply with subdivision (b) of Section 10850, Sections
14407.1, 14408, 14409, 14410, and 14411, and Title 22 of the
California Code of Regulations, including Sections 53880 and 53881 of
Title 22 of the California Code of Regulations. Each dental plan
shall submit its marketing plan to the department for review and
approval.
(f) Each dental plan shall submit its member services procedures,
beneficiary informational materials, and any updates to those
procedures or materials to the department for review and approval.
The department shall ensure that member services procedures and
beneficiary informational materials are clear and provide timely and
fair processes for accepting and acting upon complaints, grievances,
and disenrollment requests, including procedures for appealing
decisions regarding coverage or benefits.
(g) Each dental plan shall submit its provider compensation
agreements to the department for review and approval.
(h) The department shall post to its Internet Web site a copy of
all final reports completed by the Department of Managed Health Care
regarding dental managed care plans.
(i) The department shall ensure, to the greatest degree possible,
that the categories of data and performance measures selected under
this section are consistent with the categories of data and
performance measures selected under Section 14132.915.
SEC. 4. SEC. 3. Section 14184.72 is
added to the Welfare and Institutions Code, immediately following
Section 14184.71, to read:
14184.72. In connection with the evaluation of the DTI required
by Section 14184.71, the department's report of data and quality
measures submitted to the federal Centers for Medicare and Medicaid
Services (CMS) and made publicly available pursuant to the Special
Terms and Conditions for the Increase Preventive Services Utilization
for Children domain shall include, but not be limited to, all of the
following:
(a) A detailed description of how the department has
operationalized the domain, including information identifying which
entities have responsibility for the components of the domain.
(b) The number of individual incentives paid and the total amount
expended under the domain for the current program year.
(c) An awareness plan that describes all of the following:
(1) How the department has generated awareness of the availability
of incentives for providing preventive dental services to children,
including steps taken to increase awareness of the DTI among dental
and primary care providers.
(2) How the department has generated awareness among beneficiaries
of the availability of, the importance of, and how to access
preventive dental services for children.
(3) The different approaches to raising awareness undertaken among
specific groups, including age groups, rural and urban residents,
and primary language groups. These approaches shall be developed
in conjunction with interested dental and children's health
stakeholders.
(d) An annual analysis of whether the awareness plan
described in subdivision (c) has succeeded in generating the
utilization necessary, by subgrouping, to meet the goals of the
domain, and a description of changes to the awareness plan needed to
address any identified deficiencies.
(e) Data describing both of the following:
(1) The use of, and expenditures on, preventive dental services.
(2) The use of, and expenditures on, other nonpreventive dental
services.
(f) A discussion of the extent to which the metrics described for
the domain are proving to be useful in understanding the
effectiveness of the activities undertaken in the domain.
(g) An analysis of changes in cost per capita.
(h) A descriptive analysis of program integrity challenges
generated by the domain and how those challenges have been, or will
be, addressed.
(i) A descriptive analysis of the overall effectiveness of the
activities in the domain in meeting the intended goals of the domain,
any lessons learned, and any recommended adjustments.
SEC. 5. SEC. 4. Section 14184.73 is
added to the Welfare and Institutions Code, to read:
14184.73. In connection with the evaluation of the DTI required
by Section 14184.71, the department's report of data and quality
measures submitted to the federal Centers for Medicare and Medicaid
Services and made publicly available pursuant to the Special Terms
and Conditions for the Caries Risk Assessment (CRA) and Disease
Management Pilot domain shall include, but not be limited to, all of
the following:
(a) A detailed description of how the department has
operationalized the domain, including information identifying which
entities have responsibility for the components of the domain.
(b) The number of individual incentives paid and the total amount
expended, by county, under the domain in the current demonstration
year.
(c) A descriptive assessment of the impact of the domain on
targeted children in the age ranges of under one year of age, one
through two years of age, three through four years of age, and five
through six years of age, for all of the following:
(1) Provision of CRAs.
(2) Provision of dental exams.
(3) Use of, and expenditures on, preventive dental services.
(4) Use of, and expenditures on, dental treatment services.
(5) Use of, and expenditures on, dental-related general
anesthesia. anesthesia, including facility costs.
SEC. 6. SEC. 5.
Section 14184.74 is added to the Welfare and Institutions
Code, to read:
14184.74. In connection with the evaluation of the DTI required
by Section 14184.71, the department's report of data and quality
measures submitted to the federal Centers for Medicare and Medicaid
Services and made publicly available pursuant to the Special Terms
and Conditions for the Increase Continuity of Care domain shall
include, but not be limited to, all of the following:
(a) A detailed description of how the department has
operationalized the domain, including information identifying which
entities have responsibility for the components of the domain.
(b) The number of individual incentives paid and the total amount
expended, by county, under the domain in the current demonstration
year.
(c) A descriptive assessment of the impact of the domain, with
respect to targeted children, of all of the following:
(1) Provision of dental exams.
(2) Use of, and expenditures on, preventive dental services.
(3) Use of, and expenditures on, other nonpreventive dental
services.
(d) A discussion of the extent to which the metrics prescribed for
the domain are proving to be useful in understanding the
effectiveness of the activities undertaken in the domain.
(e) An analysis of change in cost per capita.
(f) A descriptive analysis of program integrity challenges
generated by the domain and how those challenges have been, or will
be, addressed.
(g) A descriptive analysis of the overall effectiveness of the
activities in the domain in meeting the intended goals of the domain,
any lessons learned, and any recommended adjustments.
SEC. 7. SEC. 6. Section 14184.75 is
added to the Welfare and Institutions Code, to read:
14184.75. In connection with the evaluation of the DTI required
by Section 14184.71, the department's report of data and quality
measures submitted to the federal Centers for Medicare and Medicaid
Services and made publicly available pursuant to the Special Terms
and Conditions for the Local Dental Pilot Program domain shall
include, but not be limited to, all of the following:
(a) A detailed description of how the department has
operationalized the domain, including information identifying
which entities have responsibility for the components of the domain.
this aspect of the demonstration project, including
the solicitation and selection process.
(b) The number of individual incentives paid
pilot projects funded and the total amount expended, by
county, project, under the domain in
the current demonstration year.
(c) A description of the pilot projects selected for award that
for each project shall include, but not be limited to, all of the
following:
(1) Specific strategies for the project.
(2) Target populations.
(3) Payment methodologies.
(4) Annual budget for the project.
(5) Expected duration of the project.
(6) Performance metrics by which the project shall be measured.
(7) The intended goal of the project.
(d) An assessment of the pilot projects selected for award that
includes for each project all of the following:
(1) Project performance and outcomes.
(2) Project replicability.
(3) Challenges encountered and actions undertaken to address those
challenges.
(4) Information on payments made by the department to the project.
(e) A descriptive assessment of the impact of the Local Dental
Pilot Program domain on achieving the goals of the Increase
Preventive Services Utilization for Children, Caries Risk Assessment
and Disease Management Pilot, and Increase Continuity of Care
domains.
(f) A descriptive analysis of program integrity challenges
generated by the domain and how those challenges have been, or will
be, addressed.
SEC. 7. Section 14459.6 of the Welfare
and Institutions Code is amended to read:
14459.6. (a) The department shall establish a list of performance
measures to ensure dental health plans meet quality criteria
required by the department. The list shall specify the benchmarks
used by the department to determine whether and the extent to which a
dental health plan meets each performance measure. Commencing
January 1, 2013, and quarterly thereafter, the list of performance
measures established by the department along with each plan's
performance shall be posted on the department's Internet Web site.
The Department of Managed Health Care and the advisory committee
established pursuant to Section 14089.08 shall have access to all
performance measures and benchmarks used by the department as
described in this section.
(1) Commencing April 30, 2017, the quarterly reporting required by
this subdivision shall be posted in the following manner:
(A) On or before April 30, 2017, the reporting shall be posted for
the July 2016 to September 2016, inclusive, fiscal quarter.
(B) After April 30, 2017, the reporting shall be posted on a
quarterly basis on or before April 30, July 31, October 31, and
January 31 for the fiscal quarter ending seven months prior.
(1)
( 2) The performance measures established by
the department shall include, but not be limited to, all of the
following: provider network adequacy, overall utilization of dental
services, annual dental visits, the total number of patients
seen on a per-provider basis and the total number of dental services
rendered by each provider during each calendar year, use of
preventive dental services, use of dental treatment services, use of
examinations and oral health evaluations, sealant to restoration
ratio, filling to preventive services ratio, treatment to caries
prevention ratio, use of dental sealants, use of diagnostic services,
and survey of member satisfaction with plans and providers.
(2)
( 3) The survey of member satisfaction with
plans and providers shall be the same dental version of the Consumer
Assessment of Healthcare Providers and Systems (CAHPS) survey as used
by the Healthy Families Program.
(3)
( 4) The department shall notify dental
health plans at least 30 days prior to the implementation date of
these performance measures.
(4)
( 5) The department shall include the
initial list of performance measures and benchmarks in any dental
health contracts entered into between the department and a dental
health plan pursuant to Section 14204.
(5)
( 6) The department shall update performance
measures and benchmarks and establish additional performance
measures and benchmarks in accordance with all of the following:
(A) The department shall consider performance measures and
benchmarks established by other states, the federal government, and
national organizations developing dental program performance and
quality measures.
(B) The department shall notify dental health plans at least 30
days prior to the implementation date of updates or changes to
performance measures and benchmarks. The department shall also post
these updates or changes on its Internet Web site at least 30 days
prior to implementation in order to provide transparency to the
public.
(C) To ensure that the dental health needs of Medi-Cal
beneficiaries are met, the department shall, when evaluating
performance measures and benchmarks for retention on, addition to, or
deletion from the list, consider all of the following criteria:
(i) Monthly, quarterly, annual, and multiyear Medi-Cal dental
managed care trended data.
(ii) County and statewide Medi-Cal dental fee-for-service
performance and quality ratings.
(iii) Other state and national dental program performance and
quality measures.
(iv) Other state and national performance ratings.
(b) In establishing and updating the performance measures and
benchmarks, the department shall consult the advisory committee
established pursuant to Section 14089.08, as well as dental health
plan representatives and other stakeholders, including
representatives from counties, local dental societies, nonprofit
entities, legal aid entities, and other interested parties.
(c) In evaluating a dental health plan's ability to meet the
criteria established through the performance measures and benchmarks,
the department shall select specific performance measures from those
established by the department in subdivision (a) as the basis for
establishing financial or other incentives or disincentives,
including, but not limited to, bonuses, payment withholds, and
adjustments to beneficiary assignment to plan algorithms. These
incentives and disincentives shall be included in the dental health
plan contracts.
(d) (1) The department shall designate an external quality review
organization (EQRO) that shall conduct external quality reviews for
any dental health plan contracting with the department pursuant to
Section 14204.
(2) As determined by the department, but at least annually, dental
health plans shall arrange for an external quality of care review
with the EQRO designated by the department that evaluates the dental
health plan's performance in meeting the performance measures
established in this section. Dental health plans shall cooperate with
and assist the EQRO in this review. The Department of Managed Health
Care shall have direct access to all external quality of care review
information upon request to the department.
(3) An external quality of care review shall include, but not be
limited to, all of the following: performance on the selected
performance measures and benchmarks established and updated by the
department, the CAHPS member or consumer satisfaction survey
referenced in paragraph (2) of subdivision (a), reporting systems,
and methodologies for calculating performance measures. An external
quality of care review that includes all of the above components
shall be paid for by the dental health plan and posted online
annually, or at any other frequency specified by the department, on
the department's Internet Web site.
(e) All marketing methods and activities to be used by dental
plans shall comply with subdivision (b) of Section 10850, Sections
14407.1, 14408, 14409, 14410, and 14411, and Title 22 of the
California Code of Regulations, including Sections 53880 and
53881. 53881 of Title 22 of the California Code of
Regulations. Each dental plan shall submit its marketing plan
to the department for review and approval.
(f) Each dental plan shall submit its member services procedures,
beneficiary informational materials, and any updates to those
procedures or materials to the department for review and approval.
The department shall ensure that member services procedures and
beneficiary informational materials are clear and provide timely and
fair processes for accepting and acting upon complaints, grievances,
and disenrollment requests, including procedures for appealing
decisions regarding coverage or benefits.
(g) Each dental plan shall submit its provider compensation
agreements to the department for review and approval.
(h) The department shall post to its Internet Web site a copy of
all final reports completed by the Department of Managed Health Care
regarding dental managed care plans.
(i) The department shall ensure, to the greatest degree possible,
that the categories of data and performance measures selected under
this section are consistent with the categories of data and
performance measures selected under Section 14132.915.
