Report 2013-125 Recommendation 4 Responses

Report 2013-125: California Department of Health Care Services: Weaknesses in Its Medi-Cal Dental Program Limit Children's Access to Dental Care (Release Date: December 2014)

Recommendation #4 To: Health Care Services, Department of

To ensure that child beneficiaries throughout California can reasonably access dental services under Medi-Cal and to increase child beneficiary utilization and provider participation, Health Care Services should take the following steps for the fee-for-service delivery system by May 2015: immediately take action to resolve any declining trends identified during its monitoring efforts.

Annual Follow-Up Agency Response From October 2019

DHCS has taken actions in launching the Smile, California campaign to increase eligible beneficiaries' use of Medi-Cal's dental benefit, increase awareness, and educate eligible beneficiaries about the free and low-cost services available to help maintain a healthy smile, and reduce any barriers accessing care. In addition, the Administrative Services Contractor conducted outreach to providers. Providers are also incentivized through the DTI and Proposition 56 supplemental payments, which has contributed to positive trends in annual dental visits between calendar year 2016 to 2018.

California State Auditor's Assessment of Annual Follow-Up Status: Fully Implemented

Annual Follow-Up Agency Response From November 2018

As a follow up to the initiatives addressed in the previous response, DHCS plans to, but has had to postpone, conducting trend analysis to enable inclusion of complete DTI Program Year (PY) two, Proposition 56 2017-18 supplemental payments, and adult restoration data.

DHCS will perform a data analysis of the past three fiscal years (2015-16, 2016-17, and 2017-18) and publish those results by end of July 2019.

California State Auditor's Assessment of Annual Follow-Up Status: Pending

Annual Follow-Up Agency Response From September 2017

DHCS addressed this recommendation by implementing and monitoring annual beneficiary and provider outreach plans. In 2017, DHCS is focused on beneficiary outreach in 23 underserved counties and increasing provider recruitment through various outreach efforts, i.e. letter campaigns, one-on-one enrollment assistance, presentations to dental schools and allied dental professional programs. DHCS is enhancing provider retention through training seminars, on-site visits, satisfaction surveys, and redesigning customer support through consumer friendly print materials, online, and mobile applications. DHCS is using alternative service delivery modalities to increase beneficiaries' access to services, including six mobile dental vans, school based health centers, and teledentistry (733 claims billed as of June 2017). DHCS implemented and is monitoring the DTI which has demonstrated both a 1.3 percent increase in utilization of preventive services for children in 2016 and an increase in Medi Cal dentists providing preventive dental services to at least ten children by 5.4 percent. 2017 DTI incentive payments by Domain (D) to date: D1 - $24 million to 2,646 dental locations statewide for providing preventive services; D2 - $486,122 to providers utilizing Caries Risk Assessments to diagnose early childhood caries; 88 providers have opted-in; D3 - $9.2 million to 684 dental service office locations in 17 pilot counties for ensuring continuity of care; and, D4 - 11 of 15 local dental pilot projects have been implemented (4 are still under DHCS review). DHCS continues to implement AB 2207 provisions, including a number of per-provider reports due from DHCS to be posted by July 2019.

California State Auditor's Assessment of Annual Follow-Up Status: Partially Implemented

We cannot confirm that DHCS fully implemented this recommendation. Although DHCS provided documents supporting its implementation of measures related to dental access (e.g., number of dental providers, beneficiary utilization by region and total, and a comparison of Medi-Cal dental reimbursement rates to other states' rates), these documents noted that DHCS will perform its first analysis on data for FYs 2015-16 and 2016-17. DHCS did not provide documents related to the results of its data analysis for these two fiscal years nor any actions it took in response to declining trends it identified therefrom.

Annual Follow-Up Agency Response From November 2016

DHCS compiled reports related to beneficiary utilization and provider participation measures as part of its monitoring efforts. These reports support DHCS in identifying county-specific improvement areas and aid in selection of counties for the annual outreach plans to resolve identified declining trends. Additionally, DHCS Dental Transformation Initiative (DTI) received CMS approval December 30, 2015; the first demonstration year began January 1, 2016. DHCS will evaluate how the DTI, funded up to $750 million over five years, impacts children's utilization of preventive services, decreases caries, and improves continuity of care. DHCS has engaged in efforts to increase beneficiary utilization including the use of dental vans in select underserved counties, outreach to numerous County and Community agencies, school districts, and County health events. DHCS is committed to improvement of identified concerns and provided extensive technical assistance to the author's office on the provisions contained in the recently chaptered Assembly Bill (AB) 2207 (Chapter 613, Statutes of 2016). AB 2207 aims to improve Denti-Cal by confirming proper transparency and monitoring utilization of dental care, requiring DHCS to make changes to Denti-Cal's provider enrollment and disenrollment processes, increase access and utilization oversight responsibility of DHCS over its contractors, and align Denti-Cal FFS and DMC data reporting requirements. This legislation grants DHCS the ability to utilize bulletins, or the like to implement, interpret, and make specific policies and procedures for the DHCS Dental Program until regulations are adopted. This enables DHCS to achieve immediate action to resolve any declining trends identified during its monitoring efforts.

California State Auditor's Assessment of Annual Follow-Up Status: Not Fully Implemented

1-Year Agency Response

As the nature of this recommendation is ongoing, there is no definitive implementation date. Once the reporting of the beneficiary utilization and provider participation measures is complete, the results of these measures will help identify any declining trends in county-specific access to care issues and will be used as the standard benchmark criteria in the annual outreach plans. In addition, in October 2015, the Centers for Medicare and Medicaid Services (CMS) approved the exemption of dental services and applicable ancillary services from the Assembly Bill 97 ten percent provider payment reductions for dates of service on or after July 1, 2015. DHCS has implemented this exemption on a prospective basis since November 19, 2015 and expects providers to begin receiving retroactive payments for claims that were submitted before the date of implementation beginning December 2015. In addition, DHCS' dental provider incentive proposals through the Medi-Cal Waiver 2020 efforts propose $740 million to fund the incentive programs over a five-year period. Through this proposal, DHCS has the opportunity to earn an additional $10 million in funding by meeting additional performance metric criteria. The projected effective date for the Medi-Cal Waiver 2020 dental incentive programs is January 2016.

California State Auditor's Assessment of 1-Year Status: Pending

6-Month Agency Response

DHCS has established criteria for assessing provider participation and beneficiary utilization and has developed procedures for periodically identifying counties where beneficiary utilization and provider participation fail to meet applicable criteria. In accordance with the processes outlined in these procedures, DHCS will actively assess access to care and will take necessary steps to resolve declining trends that are within its purview to implement during monitoring efforts. Some mitigation strategies in order to implement may require additional resources or funding, which would be subject to approval through the annual budget process. Pursuant to the enactment of the 2015-16 California State Budget, DHCS is currently taking proactive steps to acquire federal approval to exempt dental services and applicable ancillary services from the Assembly Bill 97 10% provider payment reductions (Chapter 3, Statutes of 2011), with an effective date for dates of service on or after July 1, 2015.

California State Auditor's Assessment of 6-Month Status: Pending

60-Day Agency Response

Once DHCS has established beneficiary utilization and provider participation measures, it will actively assess access to care and immediately take necessary steps to resolve declining trends that are within its purview to implement. DHCS recognizes that some solutions may require additional resources and funding and will take the necessary steps to seek approval within the Administration in order to implement identified mitigation strategies to resolve declining trends identified during its monitoring efforts.

California State Auditor's Assessment of 60-Day Status: Pending

All Recommendations in 2013-125

Agency responses received are posted verbatim.