Implementation Review: California’s Medi-Cal Dental Program

Implementation Review: California’s Medi-Cal Dental Program Report #282 | September 2024 Milton Marks Commission on California State Government Organization and Economy www.lhc.ca.gov LITTLE HOOVER COMMISSION Dedicated to Promoting Economy and Pedro Nava Efficiency in California State Government Chair The Little Hoover Commission, formally known as the Milton Anthony Cannella Marks “Little Hoover” Commission on California State Government Vice Chair Organization and Economy, is an independent state oversight agency. Dion Aroner David Beier By statute, the Commission is a bipartisan board composed of five public members appointed by the governor, four public Asm. Phillip Chen members appointed by the Legislature, two senators and Gil Garcetti two assemblymembers. José Atilio Hernández Jason Johnson In creating the Commission in 1962, the Legislature declared Sen. Dave Min its purpose: Asm. Liz Ortega ...to secure assistance for the Governor and itself in Janna Sidley promoting economy, efficiency and improved services in the Sen. Scott Wilk transaction of the public business in the various departments, agencies and instrumentalities of the executive branch of the state government, and in making the operation of all COMMISSION STAFF state departments, agencies and instrumentalities, and Ethan Rarick all expenditures of public funds, more directly responsive to the wishes of the people as expressed by their elected Executive Director representatives... Tamar Foster Deputy Executive Director The Commission fulfills this charge by listening to the public, Krystal Beckham consulting with the experts and conferring with the wise. In the Daniel Harris-McCoy course of its investigations, the Commission typically empanels advisory committees, conducts public hearings and visits Ashley Hurley government operations in action. Shara McAlister Allie Powell Its conclusions are submitted to the Governor and the Legislature for their consideration. Recommendations often take the form of legislation, which the Commission supports through the legislative process. Contacting the Commission All correspondence should be addressed to the Commission Office: Little Hoover Commission 925 L Street, Suite 805, Sacramento, CA 95814 (916) 445-2125 | LittleHoover@lhc.ca.gov This report is available from the Commission’s website at www.lhc.ca.gov. Letter from the Chair September 10, 2024 The Honorable Gavin Newsom Governor of California The Honorable Mike McGuire The Honorable Brian Jones President pro Tempore of the Senate Senate Minority Leader and members of the Senate The Honorable Robert Rivas The Honorable James Gallagher Speaker of the Assembly Assembly Minority Leader and members of the Assembly DEAR GOVERNOR AND MEMBERS OF THE LEGISLATURE: In 2016, the Little Hoover Commission released a comprehensive study of California’s Medi-Cal Dental Program, formerly known as Denti-Cal. After additional reviews of the program, and a new report, California still ranks among the worst in the nation when it comes to care and treatment of pediatric dental disease. Our initial study exposed a dysfunctional dental care system consistently falling short in caring for one third of the state’s residents and half of its children. The Commission released a series of recommendations on the program detailing steps the state should take to address enrollment and other administrative issues. This report examines the degree to which the Commission’s past recommendations have been implemented and notes any changes in the status of the issues that have increased the importance of the Commission’s recommendations. The Commission found that while the state has made progress on some of the recommendations, there is still much more that needs to be done. Californians deserve a dental program that works, and we have the resources to fix it. The Commission respectfully submits this work and stands prepared to help you take on this challenge. Sincerely, Pedro Nava, Chair Little Hoover Commission IMPLEMENTATION REVIEW: CALIFORNIA’S MEDI-CAL DENTAL PROGRAM | 1 Table of Contents EXECUTIVE SUMMARY ......................................................................3 IMPLEMENTATION REVIEW: CALIFORNIA’S MEDI-CAL DENTAL PROGRAM ...........................................................................................5 Introduction .....................................................................................................5 I: Improving Access to Care ............................................................................6 II: Alleviating Administrative Hurdles ..........................................................7 III: A New Direction Towards Prevention ...................................................10 APPENDIX: KEY IMPLEMENTATION OF COMMISSION MEDI-CAL DENTAL PROGRAM RECOMMENDATIONS ....................................16 NOTES ................................................................................................18 2 | LITTLE HOOVER COMMISSION Executive Summary I: Improving Access to Care The Little Hoover Commission first released a report on the state’s Medi-Cal Dental program, In its initial study, the Commission found that less known at the time as Denti-Cal, in 2016. The study, than half of children covered by Medi-Cal saw spurred by a worsening epidemic of tooth decay their dentist at least once during the year. The among the state’s children, exposed a broken and Commission called on the state to set a specific dysfunctional dental care system with unnecessarily target of two-thirds of children using their benefits burdensome red tape that made it harder for annually, comparable to commercial insurance. Californians to access the dental care they need. In its report, Fixing Denti-Cal, the Commission offered In 2016, lawmakers set a 60 percent target rate for a series of recommendations to improve access annual dental utilization among Medi-Cal children to and administration of this important program. 17 years and younger. The department followed The initial report was followed by two additional up with its own targets—first in 2017 to increase reviews—Denti-Cal Still Broken in 2017 and Denti-Cal the use of preventative dental services among child Update in 2018—which examined progress made and beneficiaries by 10 percentage points and again in reiterated past recommendations. 2021 to align with the target lawmakers set in 2016. California leaders have since made significant The state has made some progress towards its goal efforts to improve this important program, including to get more children on Medi-Cal to the dental office through administrative changes to simplify onerous each year—yet it still remains that less than half of processes and a multi-million dollar initiative to covered children use their benefits annually. emphasize prevention. Yet, California still ranks II: Alleviating Administrative among the worst states in the nation when it comes to pediatric dental disease. Hurdles Last fall, the Commission initiated a limited The state’s rules and administrative processes, the review to assess implementation of its previous Commission learned, were excessively cumbersome recommendations. The Commission found that and cited as a key factor in dental providers’ eight years after issuing its initial report, one decisions to not participate in the Medi-Cal Dental recommendation was fully implemented, seven program. The Commission urged the state to were partially implemented, one has not been improve two administrative processes—enrollment implemented, and we were unable to ascertain and pre-authorization for treatment—and to purge progress on two. (See the Appendix on page 16 for the program’s regulations by eliminating those that an overview of implementation efforts). This report do more harm than good. provides updated data and outlines implementation The Department of Health Care Services (“the efforts along broad themes: access to care; department”) has taken steps to cut its red tape and administrative rules and processes; and prevention. simplify its administrative procedures. Its provider Additional research may be needed to examine new enrollment form is now online, although preliminary challenges or offer necessary recommendations for data on whether these changes have yielded a faster further reform. enrollment process are mixed. IMPLEMENTATION REVIEW: CALIFORNIA’S MEDI-CAL DENTAL PROGRAM | 3 Further, for some, the updated provider enrollment form is confusing or challenging. The department enacted administrative changes resulting in reduced turnaround times for treatment authorization requests. It also eased the administration burden on providers by creating committees focused on streamlined processes as well as member and provider engagement. III: A New Direction Towards Prevention California has historically spent most of its resources on treating, rather than preventing, dental disease. Given that rotting teeth and gum disease is largely preventable, the Commission urged leaders in state government and beyond to lead a sustained effort to build and fund a coordinated, comprehensive statewide system of preventative care. To bolster prevention efforts, the Commission also encouraged the state to enhance public education on good oral health habits, implement targeted incentive programs, and expand the use of teledentistry. The state has moved to enhance its efforts to prioritize prevention, including through incentives for preventative care as well as educational and outreach campaigns and websites highlighting the importance of good oral health. The department has also made it easier for providers to use teledentistry, although usage among fee-for-service beneficiaries has waned since the pandemic. 4 | LITTLE HOOVER COMMISSION Implementation Review: California’s Medi-Cal Dental Program Introduction In 2016, the Little Hoover Commission first released The initial report was followed by two additional a report on California’s Medi-Cal Dental program, reviews—Denti-Cal Still Broken in 2017 and Denti-Cal referred to at the time as Denti-Cal. The review was Update in 2018—which examined progress made and spurred by a worsening epidemic of rotting teeth, reiterated past recommendations. with children among those most affected. In the years since, California leaders have made In its study, the Commission found a broken and significant efforts to improve the program. dysfunctional dental care system, with burdensome Noteworthy reforms include administrative changes red tape that prevented dentists from participating to simplify onerous processes and a multi-million and left many low-income children without access to dollar initiative to emphasize prevention. Despite quality dental care. these improvements, California still ranks among the worst states when it comes to pediatric dental This work culminated in a final report, Fixing Denti-Cal, disease. A national survey from 2020 to 2021 found which was released the following year and included that in only two states did children have more a series of recommendations to help improve access decayed teeth or cavities.1 to and administration of this important program. What is the Medi-Cal Dental Program? Medi-Cal, California’s Medicaid health care program, is administered by the state’s Department of Health Care Services (“the department”). The program offers free or low-cost dental benefits to child and adult beneficiaries.2 Californians may qualify for Medi-Cal based on their income, and may also be eligible based on their age, whether they are pregnant, if they have a disability, or other specified factors.3 Approximately 15.6 million Californians were enrolled in the program as of July 2023.4 Medi-Cal beneficiaries can receive dental care under two delivery models: fee-for-service and managed care. Under the fee-for-service model, beneficiaries can receive dental services from any provider who accepts Medi-Cal and providers are reimbursed for individual services or visits. Under the managed care model, the state contracts with managed care dental plans to provide dental care to enrollees at a monthly flat rate for each enrollee. Generally, enrollees may only receive services from providers that are within their plan’s provider network. The vast majority—around 93 percent—of enrollees receive dental coverage through Medi-Cal fee- for-service. Enrollees in Los Angeles, Sacramento, and San Mateo Counties, can receive coverage through managed care plans.5 IMPLEMENTATION REVIEW: CALIFORNIA’S MEDI-CAL DENTAL PROGRAM | 5 Last fall, the Commission initiated a limited WORKING TOWARDS A HIGHER review to assess implementation of its previous UTILIZATION RATE recommendations. The Commission found that Several actions have moved the state toward the kind eight years after issuing its initial report, one of specific utilization target recommended by the recommendation was fully implemented, seven Commission. were partially implemented, one has not been implemented, and we were unable to ascertain In 2016, via SB 1098 (Cannella), lawmakers took progress on two. (See the Appendix on page 16 for a step toward implementing the Commission’s an overview of implementation efforts). recommendation and set a 60 percent target annual utilization rate for Medi-Cal children 17 years and This report provides updated data and outlines younger. The Department of Health Care Services implementation efforts along broad themes: access (“the department”) was given a year to report to to care; administrative rules and processes; and the Legislature on its progress and identify when it prevention. Additional research may be needed anticipated meeting the goal.6 to examine new challenges or offer necessary recommendations for further reform. Also in 2016, the department set a five-year goal to increase the use of preventative dental services I: Improving Access to among Medi-Cal youth (ages one to 20) by 10 percentage points—from a baseline of 37.8 percent.7 Care Later, in 2021, the department set a new goal to increase participation among child beneficiaries to In its initial study, the Commission found that less 60 percent through the California Advancing and than half of children covered by Medi-Cal saw Innovating Medi-Cal (CalAIM) initiative.8 This multi- their dentist at least once during the year. The year effort seeks to make the Medi-Cal program Commission called on the state to set a specific more coordinated, person-centered, and equitable.9 target of two-thirds of children using their benefits annually, comparable to commercial insurance. Less Than Half of Medi-Cal Children Use Their Dental Benefits Annually Annual Statewide Dental Visit Utilization Rate for Children (Ages Zero to 20) 60% 49.6% 50% 43.5% 43.7% 44.4% 44.7% 44.5% 47.2% 47.6% 46.0% 47.6% 40.9% 40% 30% 20% 10% 0% 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 Source: Adrianna Alcala-Beshara, JD, MBA, Chief, Medi-Cal Dental Services Division, California Department of Health Care Services. Written communication. December 15, 2023. On file. 6 | LITTLE HOOVER COMMISSION These participation goals have not been met, though higher in 2021. Further, the state’s utilization rate for some progress has occurred. Medicaid insured children ranked 21st nationally in that year.10 Preventative utilization among Medi-Cal youth increased by 6.4 percentage points by 2021, falling II: Alleviating short of the department’s target of 10 percentage Administrative Hurdles points. Dental utilization among children has yet to meet the 60 percent goals set by the Legislature In its initial study, the Commission found that and department. However, utilization did increase the state’s administrative and billing processes marginally in the years following the Commission’s were deterring dental providers from enrolling in initial report. But these gains were lost—and then Medi-Cal and accepting patients. For example, the some—in 2020 as a result of challenges related to the California Dental Association told the Commission coronavirus public health emergency. Utilization has that reimbursement for care was “exceptionally since climbed up toward pre-pandemic levels. time-consuming and cumbersome” and “ambiguous Children with commercial insurance have been far criteria, delayed payments, inconsistent treatment more likely to receive dental services than children authorizations and extensive documentation insured through Medi-Cal—with private-insurance requirements” led to dissatisfaction with the program utilization rates approximately 23 percentage points among providers.11 Online Provider Enrollment System Yields Mixed Results After One Year Annual Average Provider Enrollment Processing Times by Dental Plan and Provider Type 140 120 120 100 95 95 83 84 80 76 60 45 45 40 32 34 20 24 27 28 28 23 1919 27 14 21 11 28 26 21 16 17 16 25 26 0 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 Liberty DMC Health Net DMC FFS Billing FFS Rendering (Business Days) (Business Days) (Calendar Days) (Calendar Days) Note: The average DMC provider enrollment processing times include both rendering providers and billing providers. Source: Adrianna Alcala-Beshara, JD, MBA, Chief, Medi-Cal Dental Services Division, California Department of Health Care Services. Written communication. December 15, 2023. On file. IMPLEMENTATION REVIEW: CALIFORNIA’S MEDI-CAL DENTAL PROGRAM | 7 syaD fo rebmuN 27 1617 The Commission heard that improving two state Commission they needed to make multiple calls to processes—enrollment and pre-authorization for technical support to complete their application—only treatment—could lessen provider frustrations to be told that it could take six months to review, a with the Medi-Cal Dental system and encourage timeline that could be extended if issues arose.15 more dentists to accept Medi-Cal patients. The However it is unclear at this time whether the online Commission also called for a broad purging of the system has actually created a faster enrollment program’s administrative rules and processes. Here process—the goal that spurred the Commission’s we address each of these three topics in turn— recommendation for online forms. The online system enrollment, pre-authorization, and a general purging was not implemented until fall 2022, thus, only one of administrative processes. year of annual enrollment data is available. The SIMPLIFYING AND EXPEDITING PROVIDER initial results from this preliminary data are mixed. ENROLLMENT Depending on the plan, average enrollment times During the Commission’s initial study, providers either increased, decreased, or stayed the same.16 described a lengthy and overly burdensome As data becomes available for subsequent years, enrollment process, which required “mounds additional analysis will be required to determine if of paperwork,” especially when compared to the streamlined form and the online system have in commercial enrollment. The Commission learned of fact substantially shortened enrollment times. one dentist who waited three to four months to get enrolled as a provider through Medi-Cal but needed The Commission called for an only two weeks to do so in a commercial plan.12 The Commission called for an easier and faster easier and faster enrollment enrollment process by urging the state to simplify the process by urging the state to Medi-Cal provider enrollment forms for dentists and put them online. simplify the Medi-Cal provider enrollment forms for dentists THE PROVIDER ENROLLMENT FORM IS ONLINE BUT ISSUES REMAIN and put them online. The department implemented an online enrollment system in fall of 2022, replacing its paper- EASING BARRIERS TO TREATMENT based process and fulfilling the Commission’s In its initial study, the Commission learned that recommendation for this change.13 Medi-Cal dental providers were required to receive permission before performing most complicated The California Dental Association told Commission procedures. These approvals—known as treatment staff that the online application allows for a more authorization requests—were intended to reduce streamlined process. The Association said that some abuse among a few, but complicated the process of the most burdensome requirements—such as for all. Providers, who did not face pre-authorization the requirement to include a copy of every past requirements in the commercial world, cited it as lease agreement—have been eliminated and the yet another barrier to participation in the Medi-Cal application has been tailored more closely to dentists Dental program. instead of physicians and other health care providers. Nevertheless, issues remain. Some find the form confusing or challenging.14 One provider told the 8 | LITTLE HOOVER COMMISSION Fee-For-Service Treatment Authorization Requests Averaged 4.5-Day Turnaround in 2022 Turnaround Time for Treatment Authorization Requests by Dental Plan ___ ----- Business Days Calendar Days 14 12 10 8 6 4 2 0 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 FFS DMC Access Liberty DMC DMC Health Net Note: In 2018, fee-for-service began calculating turnaround times in calendar days instead of business days. The times for that year are longer because they include both ways (calendar and business) of calculating turnaround. Source: Adrianna Alcala-Beshara, JD, MBA, Chief, Medi-Cal Dental Services Division, California Department of Health Care Services. Written communication. December 15, 2023. On file. These requests, the Commission heard, may also REDUCING THE WAIT TIME FOR AUTHORIZATION require patients to make multiple visits to the dentist, REQUESTS first to get assessed and then to have the procedure Due to administrative changes, turnaround times for after approval. This can be challenging for patients, treatment authorization requests have decreased especially given that many receiving dental care in recent years.17 Reductions are greatest among through Medi-Cal are low-income and may rely on fee-for-service (FFS), dropping from an average of 7.6 public transit or have inflexible work hours. business days in 2016 to 4.5 calendar days in 2022.18 The Commission stopped short of calling for an end Managed care plans also saw decreases—with to treatment authorization requests. However, it Liberty and Health Net plans dropping from an urged the state to overhaul and simplify the request average of 7.5 calendar days in 2012 to 1.5 days in process for providers. The state has made some 2022. Access plans fell from 4.5 calendar days to 3.2 progress toward this goal. We examine two ways to days in that same time period.19 measure that progress: the “turnaround time” for authorization requests, and whether or not there has been progress toward removing some procedures from the prior authorization process. IMPLEMENTATION REVIEW: CALIFORNIA’S MEDI-CAL DENTAL PROGRAM | 9 syaD fo rebmuN REDUCING THE NUMBER OF PRIOR In 2017, Senator Cannella authored SB 707 to create AUTHORIZATIONS REQUIRED an evidence-based advisory group to study and evaluate the structure, priorities, and policy decisions In 2022 the department developed a committee to of the Medi-Cal Dental program.21 However, this bill “streamline member and provider engagement.” was ultimately vetoed.22 Among other topics, this committee examines whether any procedures are candidates to be Since then, the department has taken some steps removed from prior authorization. Recently, it was to cut its red tape. In 2021, it created a policy determined that re-treatment of a decayed area no development branch to focus on “streamlined longer requires prior approval. To further decrease processes and administrative efficiency.” The administrative burden, the prior authorization department developed another committee in 2022 allowance period—the time in which an individual focused on reviewing and implementing Medi-Cal is allowed to receive services once eligibility is dental policies to “streamline member and provider determined—was extended from six to twelve engagement.” This is the panel referenced above months for all services.20 regarding prior authorizations. The committee meets bi-weekly and, in addition to its work on prior PURGING OUTDATED REGULATIONS AND authorizations, reviews whether there are increases SETTING PRIORITIES in fraud that could be addressed.23 Providers expressed frustration over onerous billing procedures, which left some dental offices chasing III: A New Direction small claims, only to eventually give up because the cost to pay staff to get the reimbursement would Towards Prevention exceed its worth. They also viewed department rulemaking to be, at times, arbitrary, and said the California has historically spent most of its resources process would lead to confusion among dentists and on treating, rather than preventing, dental disease. inadvertently harm beneficiaries. This formula, the Commission found, doomed the department to a state of constant emergency and The Commission, while recognizing the repeatedly being hauled before the Legislature to understandable need to root out fraud, encouraged explain its inability to keep up with demand. The the department to reassess its policies to ensure Commission urged the state to move away from they focused first on the needs of beneficiaries and funding damage control—known as drill and fill—and avoided requirements that did more harm than instead focus on preventative care and intervention good. This regulatory streamlining, the Commission at the youngest age possible. The Commission’s urged, should be done by a small team with oversight report offers recommendations to reorient the from the Legislature. The Commission also called program around prevention. for the creation of a new advisory group, consisting A STATEWIDE SYSTEM OF PREVENTATIVE of the state dental director and expert specialists, to CARE guide development of Medi-Cal dental priorities and Throughout its initial review, the Commission heard oversee policy decisions. The group, among other that rotting teeth and gum disease could largely be things, could help weigh in on proposed decisions prevented. Yet, for many Medi-Cal beneficiaries this and make sure they are not based just on cost but was not the case. also the best evidence and science. 10 | LITTLE HOOVER COMMISSION California needed to place a greater emphasis California’s Medi-Cal Population on curbing and preventing dental disease. The July 2023 Commission recommended that leaders in state government and beyond push forward a Sex Number Percentage sustained effort to build and fund a coordinated, Male 8,283,253 53% comprehensive statewide system of preventative Female 7,292,618 47% care. The Commission also called for public Total 15,575,871 messaging campaigns to educate children and families about important oral health habits. Age Number Percentage Ages 0-20 5,750,393 37% In the years since the Commission’s initial review, the Ages 21-64 8,333,528 54% state has moved to enhance prevention efforts. Ages 65+ 1,491,947 10% In 2016, the state launched its five-year Dental Unknown 3 <0.1% Transformation Initiative to increase the use of Total 15,575,871 preventative services, reduce tooth decay, and Race/Ethnicity Number Percentage improve continuity of care among Medi-Cal children. Parts of the program were improved upon and Hispanic 7,901,214 51% permanently implemented through CalAIM in 2022. White 2,560,077 16% The state is also in the midst of implementing its Asian/Pacific Islander 1,453,431 9% 10-year prevention-focused Oral Health Plan that African-American 1,075,837 7% launched in 2018. American Indian/Alaskan 55,302 0.4% Native In fall of 2018, the department launched educational Not Reported 2,530,010 16% and outreach campaigns and websites Smile, California and its Spanish counterpart, Sonríe, Total 15,575,871 California.24 Utilizing plain language and age-specific Primary Language Number Percentage content, these efforts seek to make Medi-Cal English 10,154,010 65% members aware of their dental benefit and the Spanish 4,326,072 28% importance of good oral health with the goal of All Chinese 269,276 2% motivating them to visit the dentist. The department Vietnamese 219,411 1% has worked with a variety of stakeholder groups, including those focused on improving the health of All Other 537,662 3% children and families, to reach and share messages Unknown 69,440 0.4% to members.25 Total 15,575,871 Advocates and providers told the Commission that Note: All Chinese includes: Mandarin, Cantonese, and Other Chinese. these campaigns have made significant strides in Due to rounding, the percentages may not total 100. improving public education.26 Source: California Department of Health Care Services. “Medi-Cal Monthly Eligible Fast Facts.” October 2023 (Date represented: July 2023). https://www.dhcs.ca.gov/dataandstats/statistics/Documents/ FastFacts-July2023.pdf. IMPLEMENTATION REVIEW: CALIFORNIA’S MEDI-CAL DENTAL PROGRAM | 11 Teledentistry Use Among Fee-For-Service Beneficiaries Peaked During the Pandemic Teledentistry Utilization Among Medi-Cal Dental Beneficiaries by Delivery System 2015 2016 2017 2018 2019 2020 2021 2022 DMC FFS Source: Adrianna Alcala-Beshara, JD, MBA, Chief, Medi-Cal Dental Services Division, California Department of Health Care Services. Written Communication. December 15, 2023. On file. encourage dentists to offer preventative services to INCENTIVIZING PREVENTION youth aged 21 and younger. Part of California’s prevention prioritization problem, the Commission heard, stemmed from its low These incentives helped the state make progress reimbursement rates—among the lowest in nation towards its goal to increase the use of preventative at the time—which put pressure on providers to dental care by children enrolled in Medi-Cal. ensure financial viability by performing high-value, However, program evaluators concluded that particularly high-cost, restorative care. the confusing benchmark-based structure may have limited their impact. Additionally, they found The Commission refrained from making that barriers to prevention extended beyond low recommendations regarding wholesale reimbursement rates. Evaluators added that some reimbursement rate hikes during its study. Instead, dentists might benefit from supplemental support, the Commission suggested that the state offer including training to help them become comfortable smaller targeted incentives to boost preventative and confident in treating infants and young care. Its recommendations were based on programs children.28 in Washington State and Alameda County, which, among other things, gave dental providers training In 2022, the department introduced new prevention in treating young children and incentives to treat incentives through the CalAIM initiative that children and provide early preventative care.27 are easier to implement and for providers to understand.29 Between 2016 and 2021, California piloted a program as part of its Dental Transformation Initiative to 12 | LITTLE HOOVER COMMISSION 672,3 411,9 809,3 239,01 339,4 280,21 450,5 624,51 897,9 378,71 335,41 336,91 462,22 759,21 107,63 219,11 40,000 35,000 30,000 25,000 20,000 15,000 10,000 5,000 seiraicfieneB fo rebmuN 0 Medi-Cal Dental Providers: Where Are We Now Fee-for-service (FFS) Medi-Cal dental provider enrollment rose steadily from 2017 to 2022, at which point it briefly dropped. Since then, the number of dental providers has increased, reaching nearly 13,000 in June 2024.30 FEE-FOR-SERVICE MEDI-CAL DENTAL PROVIDER ENROLLMENT REACHED NEARLY 13,000 IN JUNE 2024 Monthly Statewide Fee-For-Service Medi-Cal Dental Rendering Provider Enrollment Note: A previous version of this chart provided a different total number of fee-for-service rendering providers. That total had been provided to the Commission by the Department of Health Care Services. After the initial publication of this report, the department informed the Commission that the previous data included duplicate counts for those providers registered in more than one county. At the Commission’s request, the department then provided revised data representing unduplicated counts for fee-for-service rendering providers. That data is the basis for this chart. The initial version of this chart also included provider enrollment data for managed care plans, although the department subsequently informed the Commission it could not immediately provide unduplicated data for managed care providers from 2012 to current, as requested. Source: California Health and Human Services Agency, Department of Health Care Services. Medi-Cal Dental Fee-For-Service (FFS) Monthly Provider Enrollment Count. Last updated: July 31, 2024. https://bit.ly/48tMxsk. IMPLEMENTATION REVIEW: CALIFORNIA’S MEDI-CAL DENTAL PROGRAM | 13 sredivorP gniredneR fo rebmuN 14,000 12,000 10,000 8,000 6,000 4,000 2,000 0 61-luJ 61-ceD 71-yaM 71-tcO 81-raM 81-guA 91-naJ 91-nuJ 91-voN 02-rpA 02-peS 12-beF 12-luJ 12-ceD 22-yaM 22-tcO 32-raM 32-guA 42-naJ 42-nuJ 14,000 12,000 10,000 8,000 6,000 4,000 2,000 0 61 luJ 61 ceD 71 yaM 71 tcO 81 raM 81 guA 91 naJ 91 nuJ 91 voN 02 rpA 02 peS 12 beF 12 luJ 12 ceD 22 yaM 22 tcO 32 raM 32 guA 42 naJ 42 nuJ While the overall number of Medi-Cal dental providers in California has increased since the Commission’s review, more counties lack a single provider within their jurisdictions to provide dental care to Medi-Cal patients. In 2015, six counties had no such dental providers. That number jumped to ten by 2022. These counties are mostly located within the Eastern Sierras, Central Valley, and northern parts of the state.31 Acute provider shortages—combined with other challenges, including geographic isolation, higher rates of poverty, and larger elderly population—contribute to rural oral health disparities.32 TEN COUNTIES HAVE NO MEDI-CAL PROVIDERS TO TREAT DENTAL PATIENTS Counties with Zero Fee-For-Service Medi-Cal Dental Rendering Providers (2022) Note: This data reflects fee-for-service (FSS) providers who rendered one or more service(s) in the 2022 calendar year. It does not count providers who are enrolled but did not render services. Counties with zero FFS rendering providers include: Alpine, Amador, Del Norte, Inyo, Mariposa, Modoc, Plumas, Sierra, Tehama, and Trinity. Source: Adrianna Alcala-Beshara, JD, MBA, Chief, Medi-Cal Dental Services Division, California Department of Health Care Services. Written communication. December 15, 2023. On file. 14 | LITTLE HOOVER COMMISSION SCALING UP TELEDENTISTRY The state also funded virtual dental home pilot projects from February 2017 to December 2020 as When the Commission conducted its initial study, part of the Dental Transformation Initiative. Over teledentistry was emerging as a promising model to the course of the pilots—which took place in four enhance preventive care. Known also as the virtual communities in five different counties across the dental home, this model allows dental care to be state—nearly 13,000 children received diagnostic, provided directly in communities and is a convenient preventative, and early intervention dental services in and cost-effective means of preventative treatment. community settings via teledentistry.35 The Commission urged state leaders to fund a State funding for pilot projects ended with the statewide expansion of teledentistry. To help scale completion of the Dental Transformation Initiative. up this concept, the Commission recommended the However, some pilots received funding from Legislature pass AB 648 (Low, 2016), which would alternative sources to sustain certain activities in the have established a grant program to provide funding short term. This includes Riverside County, which to support growth of the virtual dental home.33 The received a follow-up grant through First 5 Riverside to bill was held in the Senate Appropriations Committee further develop its home visiting program to include because the funding was not included in the state dental care.36 budget. TELEDENTISTRY GROWTH GREATEST AMONG RECENT EFFORTS TO EXPAND USE OF DENTAL MANAGED CARE BENEFICIARIES TELEDENTISTRY Teledentistry use has grown significantly since the Despite the failure of AB 648, numerous actions have passage of a 2014 law enabling dental assistants and increased the use of teledentistry. dentists to bill Medi-Cal for their work while using this method.37 The bulk of this growth stems from During the coronavirus public health emergency, dental managed care plans, with over eleven times as the department authorized expanded use of many beneficiaries taking advantage of teledentistry teledentistry for new and existing patients, including in 2022 than in 2015. Teledentistry use among fee- those served by federally qualified health centers for-service beneficiaries doubled between 2015 and rural health clinics. The policies allowed patients and 2020, at which point it peaked, and has since to connect with their dental provider virtually in dropped below 2017 levels.38 real time or to send important information, such as photos, to their dentist who could recommend a While providers commended state reforms to expand treatment plan. the use of teledentistry, some stakeholders described missed opportunities to educate Medi-Cal dental The department updated its telehealth policies in patients and providers about the availability of, and May 2023 to allow Medi-Cal dental providers to payment for, teledentistry services.39 establish patients through remote, non-real-time communication. The new policies also allowed all diagnostic and preventative services that meet specific parameters to be offered through teledentistry, expanding the number of services that could be provided through this modality.34 IMPLEMENTATION REVIEW: CALIFORNIA’S MEDI-CAL DENTAL PROGRAM | 15 Appendix: Key Implemementation of Commission Medi-Cal Dental Program Recommendations The chart below summarizes key implementation efforts of the the Commission’s recommendations from its 2016 report on California’s Medi-Cal Dental program. Two of its recommendations from the Commission’s initial report are not included due to insufficient evidence to assess progress. Recommendation Status Implementation Set a target of 66 percent of Partially State leaders set goals to raise dental utilization children with Denti-Cal coverage Implemented among Medi-Cal children, including to increase use of making annual dental visits. preventative dental services by 10 percentage points (Dental Transformation Initiative, 2016) and to set 60 percent annual utilization targets (SB 1098, Cannella, 2016 and CalAIM, 2021). The state has made some progress but has yet to meet these goals. Simplify Denti-Cal provider Fully The department implemented an online enrollment enrollment forms and put them Implemented form in October 2022. online. AB 2207 (Wood, 2016) requires the department to upgrade its provider enrollment form and make it easier for commercially credentialed dentists to enroll in Denti-Cal. Overhaul the treatment Partially Turnaround times for treatment authorization requests authorization request process. Implemented have fallen in recent years due to administrative changes. Implement a customer-focused Partially The department sends monthly provider and program to improve relations with Implemented special bulletins on new and existing policies. It also providers. holds regular stakeholder meetings and cultivates relationships with the provider community. Purge outdated regulations. Partially The department created a policy development branch Implemented in 2021 and a committee in 2022, both are focused, among other things, on streamlining and efficiency. 16 | LITTLE HOOVER COMMISSION Create in statute an evidence- No Progress Lawmakers attempted to pass legislation to create based advisory group to guide advisory bodies to assist and advice to the department development of Denti-Cal priorities regarding the Medi-Cal dental programs (SB 707, and oversee policy decisions. Cannella, 2017 and SB 1098, Cannella, 2016). Both efforts were unsuccessful. Fund a statewide expansion of Partially AB 638 (Low, 2016) would have established and teledentistry and the virtual dental Implemented provided $4 million for a grant program to support home. virtual dental homes. The bill was unsuccessful but the department has increased use of teledentistry, due in large part to new state policies initiated as a result of the coronavirus public health emergency. The state also funded local teledentistry pilot projects through the Dental Transformation Initiative (2017 to 2020). Reorient the oral health care Partially The state put forth two statewide efforts to expand system for Denti-Cal beneficiaries Implemented preventative care—the 10-year Oral Health Plan in toward preventative care. 2018 and the five-year Dental Transformation Initiative (DTI) in 2016. Parts of DTI permanently implemented through CalAIM in 2022. In 2018, the department launched English and Spanish- language educational and outreach campaigns and websites to increase dental visits and good oral health among Medi-Cal dental beneficiaries. Lawmakers attempted to pass legislation to increase provider reimbursement rates for certain dental services (AB 15, Maienschein, 2017 and AB 1051, Maienschein, 2016). Both bills were unsuccessful. Expand the concept of Washington Partially Between 2016 and 2021, the state offered incentives State’s Access to Baby and Child Implemented to dental providers to boost preventative services use Dentistry program and Alameda among Medi-Calw children (Dental Transformation County’s Healthy Kids, Healthy Initiative). Prevention incentives were also incorporated Teeth program to more regions of into CalAIM in 2022. California. IMPLEMENTATION REVIEW: CALIFORNIA’S MEDI-CAL DENTAL PROGRAM | 17 Notes 1. Note: The survey asked whether the child had 8. Adrianna Alcala-Beshara, JD, MBA, Chief, Medi-Cal frequent or chronic difficulty with decayed teeth Dental Services Division, California Department or cavities in the past 12 months. Includes only of Health Care Services. Written communication. those ages 1 to 17. Source: Data Resource Center December 15, 2023. On file. for Child & Adolescent Health. 2020-2021 Nation- 9. California Department of Health Care Services. al Survey of Children’s Health. https://www.child- Medi-Cal Transformation. https://www.dhcs. healthdata.org/browse/survey/allstates?q=9243. ca.gov/CalAIM/Pages/CalAIM.aspx. 2. Smile, California. About Medi-Cal Dental. https:// 10. American Dental Association. Dental Care Utili- smilecalifornia.org/about/. zation Among Children and Adults Dashboard. 3. California Department of Health Care Services. https://www.ada.org/en/resources/research/ Do You Qualify for Medi-Cal Benefits? https:// health-policy-institute/child-dental-care-utiliza- www.dhcs.ca.gov/services/medi-cal/Pages/DoY- tion-dashboard. ouQualifyForMedi-Cal.aspx. 11. Little Hoover Commission. Fixing Denti-Cal. April 4. California Department of Health Care Services. 2016. Page 30. https://lhc.ca.gov/wp-content/up- “Medi-Cal Monthly Eligible Fast Facts.” October loads/Reports/230/Report230.pdf. 2023 (Date represented: July 2023). https://www. 12. Little Hoover Commission. Page 31. See endnote dhcs.ca.gov/dataandstats/statistics/Documents/ 11. FastFacts-July2023.pdf. 13. Note: Providers under dental managed care and 5. Note: Medi-Cal beneficiaries in San Mateo County fee-for-service models must follow similar en- have the option to enroll in the Health Plan of rollment processes and both switched to using San Mateo, which transitioned from a fee-for-ser- the online PAVE provider enrollment system in vice to a managed care delivery system effec- October 2022. Source: Adrianna Alcala-Beshara, tive January 1, 2022. Source: Health Plan of San JD, MBA, Chief, Medi-Cal Dental Services Division, Mateo. “Transition of Dental Services from Fee- California Department of Health Care Services. for Service to Managed Care Delivery System.” Written communication. June 28, 2024. On file. https://www.hpsm.org/docs/default-source/ hpsm/hpsm-transition-plan---integration-of-den- 14. Monica Montano, Regulatory and Legislative tal-services.pdf?sfvrsn=17c2c345_2. Also, Califor- Advocate, California Dental Association. Written nia Dental Association. Improvements to the Oral communication. December 20, 2023. On file. Health of Californians. On file. 15. Paul Glassman DDS, MA, MBA, Professor and 6. Senate Bill 1098 (Cannella). Chapter 630, Statutes Associate Dean for Research and Community En- of 2016. https://leginfo.legislature.ca.gov/faces/ gagement, College of Dental Medicine, California billTextClient.xhtml?bill_id=201520160SB1098. Northstate University. Written communication. February 29, 2024. On file. 7. California Department of Health Care Services. “Dental Transformation Initiative (DTI), Final An- 16. Note: DMC Access reported an estimated annual nual Report Period, Program Year 6 (01/01/2021 average of 30 to 60 calendar days from 2012 to – 12/31/2021). https://www.dhcs.ca.gov/services/ 2022 and an average of 101 days in 2023. In 2023, Documents/MDSD/DTI%20Materials/DTI-PY6-Fi- Access’ enrollment times were calculated in both nal-Annual-Report.pdf. business and calendar days. According to Access 18 | LITTLE HOOVER COMMISSION Dental Plan, the increase in processing times in 22. Office of the California Governor Edmund G. 2023 was due to moving provider enrollment pro- Brown Jr. SB 707 Veto Message. September 26, cesses from the parent organization to a direct 2018. https://archive.gov.ca.gov/archive/gov39/ affiliate of ADP in 2023. The extended periods to wp-content/uploads/2018/09/SB-707-Veto.pdf. enroll providers occurred as new staff were being 23. Adrianna Alcala-Beshara. See endnote 8. trained and processes refined including specific tracking of key performance indicators that now 24. Note: Find the Smile, California website here: include provider enrollment metrics. For year-to- https://smilecalifornia.org/. Find the Sonríe, Cali- date in 2024, the provider enrollment processing fornia website here: https://sonriecalifornia.org/. times have dropped to 41 calendar days. Source: Sabrina Sierras, Audit Coordination Manager, 25. Adrianna Alcala-Beshara. See endnote 8. Office of Compliance, Internal Audits, California Department of Health Care Services. August 1, 26. Dennis Cuevas-Romero, Esq., Vice President of 2024. Written communication with Commission Government Affairs, California Primary Care As- staff. sociation. Written communication. March 1, 2024. On file. 17. Note: The department attributes reductions among fee-for-service to its efforts to ensure high 27. Note: These programs include the Access to Baby levels of accountability with contractors respon- and Children Dentistry (ABCD) program in Wash- sible for processing these types of requests. ington State and the Healthy Kids, Healthy Teeth Decreases in processing times among managed program in Alameda County. Additional details care plans, the department says, are due to a on these programs can be found beginning on contractual obligation to meet a five-day business page 48 of the Commission’s 2016 Denti-Cal turnaround time, established in 2018. Source: report: https://lhc.ca.gov/wp-content/uploads/ Adrianna Alcala-Beshara, JD, MBA, Chief, Medi-Cal Reports/230/Report230.pdf. Dental Services Division, California Department of Health Care Services. Written communication. 28. Sean Orzol, et al. Evaluation of the Dental Trans- July 11, 2024. On file. formation Initiative, Final Evaluation Report. Submitted by Mathematica to the Medi-Cal Den- 18. Note: Beginning in 2018, the department started tal Services Division, Department of Health Care calculating turnaround time for fee-for-service Services. June 13, 2023. https://www.dhcs.ca.gov/ treatment authorization requests using calendar provgovpart/Documents/DTI-Evaluation-Final-Re- days instead of business days. Source: Adrianna port.pdf. Alcala-Beshara. See endnote 8. 29. Monica Montano. See endnote 14. 19. Note: This includes a combined average for both the Sacramento Geographic Managed Care 30. California Health and Human Services Agency, and Los Angeles Prepaid Health Plan programs. Department of Health Care Services. Medi-Cal Source: Adrianna Alcala-Beshara. See endnote 8. Dental Fee-For-Service (FFS) Monthly Provider Enrollment Count. Last updated: July 31, 2024. 20. Adrianna Alcala-Beshara. See endnote 8. https://bit.ly/48tMxsk. 21. SB 707 (Cannella, 2017). https://leginfo.legis- 31. Note: These counties are Alpine, Amador, Del lature.ca.gov/faces/billNavClient.xhtml?bill_ Norte, Inyo, Mariposa, Modoc, Plumas, Sierra, id=201720180SB707. Tehama, and Trinity. IMPLEMENTATION REVIEW: CALIFORNIA’S MEDI-CAL DENTAL PROGRAM | 19 32. U.S. Department of Health and Human Services, National Advisory Committee on Rural Health and Human Services. “Improving Oral Health Care Services in Rural America.” December 2018. https://www.hrsa.gov/sites/default/files/hrsa/ advisory-committees/rural/2018-oral-health-poli- cy-brief.pdf. 33. AB 648 (Low, 2016). https://leginfo.legisla- ture.ca.gov/faces/billNavClient.xhtml?bill_ id=201520160AB648. 34. Monica Montano. See endnote 14. Also, Depart- ment of Health Care Services, Medi-Cal Dental. Provider Bulletin: Volume 39 Number 9. April 2023. https://www.dental.dhcs.ca.gov/MCD_doc- uments/providers/provider_bulletins/Volume_39_ Number_08.pdf. 35. Note: These counties are Orange, Riverside, San Bernardino, Sacramento, and San Joaquin. Source: Monica Montano. See endnote 14. 36. Sean Orzol, et al. See endnote 28. 37. AB 1174 (Bocanegra and Logue), Chapter 662, Statutes of 2014. https://leginfo.legis- lature.ca.gov/faces/billNavClient.xhtml?bill_ id=201320140AB1174. 38. Note: The Health Plan of San Mateo came effec- tive at the start of 2022 and beneficiaries utilized teledentistry in that year. Additionally, an aver- age of 210 PACE (Program of All-Inclusive Care) members accessed teledentistry each year from 2019 to 2022. Source: Adrianna Alcala-Beshara. See endnote 8. 39. Dennis Cuevas-Romero. See endnote 26. 20 | LITTLE HOOVER COMMISSION Little Hoover Commission Members CHAIR PEDRO NAVA | Santa Barbara JOSÉ ATILIO HERNÁNDEZ | Burbank Appointed to the Commission by Speaker of the Assembly Appointed by Speaker of the Assembly Anthony Rendon John Pérez in April 2013 and reappointed by Speaker in April 2023. Founder and CEO of IDEATE California, a of the Assembly Anthony Rendon in 2017 and again public relations and policy management firm. Also, founder in 2021. Government relations advisor. Former State and Board Chairman of ideateLABS. Former Director for Assemblymember from 2004 to 2010, civil litigator, External Affairs and Community Relations for ConnectEd: deputy district attorney and member of the state Coastal The California Center for College and Career. Commission. Elected chair of the Commission in March 2014. JASON JOHNSON | Napa Appointed by Governor Newsom in June 2023. Member VICE CHAIR ANTHONY CANNELLA | Ceres of the Land Trust of Napa County Board of Trustees and Appointed to the Commission by the Senate Rules Horary Commander of Travis Air Force Base. Former Committee in March 2022. Civil engineer and principal with Managing Partner at Founders Den. Founder and former Northstar Engineering Group. Former State Senator from CEO at August Home Inc. 2010 to 2018. Previously served on the Ceres City Council and was twice elected mayor of that city. Elected Vice Chair SEN. DAVE MIN | Irvine of the Commission in July 2023. Appointed to the Commission by the Senate Rules Committee in September 2021. Elected in November 2020 DION ARONER | Berkeley to represent the 37th Senate District. Represents Anaheim Appointed to the Commission by the Senate Rules Hills, Costa Mesa, Huntington Beach, Irvine, Laguna Beach, Committee in April 2019. Partner for Aroner, Jewel, and Laguna Woods, Lake Forest, Newport Beach, Orange, Ellis. Former State Assemblymember from 1996 to 2002, Tustin, and Villa Park. chief of staff for Assemblymember Tom Bates, social worker for Alameda County, and the first female president ASM. LIZ ORTEGA | San Leandro of Service Employees International Union 535. Appointed to the Commission by Speaker of the Assembly Anthony Rendon in March 2023. Elected in November DAVID BEIER | San Francisco 2022 to represent the 20th Assembly District. Represents Appointed to the Commission by Governor Edmund G. Hayward, San Leandro, most of Union City, portions Brown Jr. in June 2014 and reappointed in January 2018. of Dublin and Pleasanton, and several unincorporated Managing director of Bay City Capital. Former senior officer communities. of Genentech and Amgen, and counsel to the U.S. House of Representatives Committee on the Judiciary. JANNA SIDLEY | Los Angeles Appointed to the Commission by Governor Edmund G. ASM. PHILLIP CHEN | Yorba Linda Brown Jr. in April 2016 and reappointed in February 2020. Appointed to the Commission by Speaker of the Assembly Partner at Ichor Strategies and appointed to the Board Anthony Rendon in October 2021. Elected in November of the Los Angeles City Employee Retirement System 2016 to represent 55th District. Represents portions of Los (“LACERS”). Former general counsel at the Port of Los Angeles, Orange and San Bernardino counties and the Angeles and city attorney at the Los Angeles City Attorney’s cities of Brea, Chino Hills, Diamond Bar, La Habra, Industry, Office. Placentia, Rowland Heights, Walnut, West Covina and Yorba Linda. SEN. SCOTT WILK | Santa Clarita Appointed to the Commission by the Senate Rules GIL GARCETTI | Los Angeles Committee in April 2023. Elected in November 2016 to Appointed to the Commission by Governor Gavin Newsom represent the 21st Senate District. Represents communities in November 2021. Professional photographer and author in the Antelope, Santa Clarita, and Victor Valleys. of ten books. Former Los Angeles County District Attorney, Full biographies are available on the Commission’s teaching Fellow at Harvard University’s Kennedy School, website at www.lhc.ca.gov. and president of the California Science Center Foundation’s Board of Trustees. “DEMOCRACY ITSELF IS A PROCESS OF CHANGE, AND SATISFACTION AND COMPLACENCY ARE ENEMIES OF GOOD GOVERNMENT.” By Governor Edmund G. “Pat” Brown, addressing the inaugural meeting of the Little Hoover Commission, April 24,1962, Sacramento, California Milton Marks Commission on California State Government Organization and Economy www.lhc.ca.gov