Brushing up on Innovations in State Oral Health Policy: California s Dental Transformation Initiative & More Alani Jackson, MPA Chief, Medi-Cal Dental Services Division California Department of Health Care Services October 25, 2017 1) Brief Medi-Cal Dental Program Overview 2) 2020 Waiver: 3) Proposition 56 Tobacco Tax Funds Supplemental Payments for Select Dental Services 4) Adult Dental Restoration 5) Questions Presentation Outline 2 1
Medi-Cal Dental Services Overview Total Medi-Cal population Approximately 13.9 million beneficiaries Total dental program budget Approximately $1.2 billion based on the current State budget Two delivery systems: fee-for-service (FFS) (all 58 counties); dental managed care (DMC) (Sacramento 80% DMC/20% FFS and Los Angeles Counties 14% DMC/86% FFS) Number of SNCs rendering dental services Approximately 430 clinics; number of services provided by SNCs Approximately 1,345,000 (Children) and 1,545,000 (Adults) Program Period & Funding Overview DTI 01/01/16 12/31/20 $740M 4 2
Medi-Cal 2020: Domain 1: Increase Preventive Services Utilization for Children Domain 3: Increase Continuity of Care Domain 4: Local Dental Pilot Programs (LDPPs) 5 Domain 1: Increase Preventive Services Utilization for Children Priority Data from the National Survey of Children's Health 2011 2012: Approximately 11% of children aged 1 5 years reported oral health problems. Approximately 53% reported one or more preventive dental care visits. 6 3
Domain 1: Increase Preventive Services Utilization for Children Domain Goal Increase statewide proportion of children ages 1 20 enrolled in Medi Cal who receive a preventive dental service by 10 percentage points over five years Payment Twice a year January and July 75% SMA or 37.5% Based on claims for 11 preventive CDT codes 7 Domain 1: 1: Increase Preventive Services Utilization Utilization for for Children Children First Payment: January 2017 Second Payment: July 2017 Total Domain 1 Payment as of 09/14/2017 Amount Svc. Off. Loc. Amount Svc. Off. Loc. Total Amount FFS $20.9M 2,332 $561K 2,460 $21.4M DMC $491,342 156 $608K 949 $1.1M SNC $606,509 64 $1.03M 204 $1.6M Total $22M 2,552 $2.2M 3,613 $24.2M 8 4
Domain 2: Caries Risk Assessment and Disease Management Pilot Priority Data from the National Health and Nutrition Examination Survey, 2011 2012: Approximately 23% of children aged 2 5 years had dental caries in primary teeth. Approximately 10% of children aged 2 5 years had untreated dental caries in primary teeth. 9 Early Childhood Caries Prevalence per 10 Children Sources: Iida H, Auinger P, Billings RJ, Weitzman M. PEDIATRICS 120 (4):2007. Dental Health Foundation. The California Smile Survey. An Oral Health Assessment of California s Kindergarten and 3rd Grade Children. 2006 10 5
Domain 2: Caries Risk Assessment and Disease Management Pilot Domain Goals Diagnose Early Childhood Caries (ECC) by utilizing Caries Risk Assessments (CRA) to treat it as a chronic disease. Introduce a model in 11 counties that proactively prevents and mitigates oral disease through the delivery of preventative services in lieu of more invasive and costly procedures (restorativeservices). Identify the effectiveness of CRA and treatment plans for children ages 6 and under. 11 Domain 2: Caries Risk Assessment and Disease Management Pilot Criteria Treatment plans and associated procedures will be carried out as follows, over a 12 month period: High Risk children will be authorized to visit 4 times per year. Moderate Risk children will be authorized to visit 3times per year. Low Risk children will be authorized to visit 2 times per year (current benefit). 12 6
Domain 2: Caries Risk Assessment and Disease Management Pilot The CRA procedure bundle consists of three CDT codes which must be performed on the same date of service and submitted together on one claim. 1. Caries Risk Assessment ($15.00) od0601 Low Risk (twice a year) od0602 Medium Risk (three times a year) od0603 High Risk (four times a year) 2. Nutritional Counseling ($46.00) o D1310 3. Motivational Interview ($65.00) o D9993 13 Domain 2: Caries Risk Assessment and Disease Management Pilot In addition to the CRA procedure bundle, for high risk patients, interim caries arresting medicament (Silver Diamine Fluoride) may be performed as needed but is reimbursed no more than twice per year. o D1354 ($35.00) a benefit every six months for a whole mouth treatment. o D1354 does not have to be performed at the time of CRA and a claim for reimbursement does not have to be submitted on the same claim as the CRA procedure bundle. 14 7
Domain 2: Caries Risk Assessment and Disease Management Pilot Provider Participation Process Dentists can opt in by completing an attestation and a webinar training program. A certificate of completion will be provided for submission. Webinar Training Treating Young Kids Everyday (TYKE) offered by the California Dental Association (CDA). www.cda.org/tyke. 180 days of access for course completion. No Cost to CDA members/non members. 2 CE awarded. 15 As of September 14, 2017: Total Payment: $669,382 233 providers completed TYKE training 94 providers participating in 11 counties Outreach Efforts: collaboration with professional societies, FI, and DMC 16 8
Domain 3: Increase Continuity of Care Priority Too many people mistakenly believe that their children need to see a dentist only if they are in pain or think something is wrong. Continuity of care is working with the same practice and same dentist over time to establish a dental home, and to ensure that treatment continues in the right direction and future potential problems can be addressed before they become more serious. 17 Domain 3: Increase Continuity of Care Domain 3: Continuity of Care Domain Goal Increase continuity of care for beneficiaries ages 20 and under for 2, 3, 4, 5, and 6 year continuous periods. Claims data in 17 pilot counties will determine the number of beneficiaries who received a qualifying examination (D0120, D0150 or D0145) each year from the same service office location for two (2), three (3), four (4), five (5) and six (6) year continuous periods. 18 9
Domain 3: Increase Continuity of Care Domain 3: Continuity of Care First Annual Payment in June 30, 2017 was for $9.4 Million FFS $9.2M/ 684 SOL SNC $184,320/ 8 SOL Next Annual Payment June 30, 2018 19 Domain 4: Local Dental Pilot Programs (LDPPs) Project Goal LDPPS will address 1 or more of the 3 domains through alternative programs, potentially using strategies focused on rural areas including local case management initiatives and education partnerships DHCS solicited proposals once at the beginning of the demonstration 15 LDPPs were approved Implementation date: February 2017. Metric Benchmarking LDPPs will be evaluated consistent with the performance metric of the aforementioned dental domains and the goals outlined in the individual proposals 20 10
CA Healthcare, Research & Prevention Tobacco Tax Act Prop.56 AB 120(Statutes of 2017, Chapter 22, 3, Item 4260 101 3305), allocates funds for specific DHCS health care expenditures during the 17/18 state fiscal year including up to $140M for supplemental payments on select dental services for providers who bill the Dental FI or DMC plans. Categories of dental services: Restorative Endodontic Prosthodontic Oral and maxillofacial Adjunctive Visits and diagnostics Proposition 56 Tobacco Tax Funds 21 Proposition 56 Tobacco Tax Funds Contingent on Federal Approval Supplemental payment at a rate equal to 40% of the Dental Schedule of Maximum Allowances (SMA) for specified codes for dates of service during July 1, 2017 June 30, 2018 Once approved, supplemental payments will be retroactive to July 1, 2017. For more information on Prop. 56, please visit: Public Notice: http://www.dhcs.ca.gov/provgovpart/documents/public%2 0Notices/17 031_Dental_Prop56_Public_Notice.pdf Provider Bulletin August 2017 issue list of procedure codes http://www.dentical.ca.gov/provsrvcs/bulletins/volume_33_number_09.pdf 10/6/2017 22 11
Restoration of Adult Dental Services AB113 Contingent on Federal Approval Effective Date: January 1, 2018 Restoring all optional adult dental benefits eliminated in 2009 and not restored in 2014 Stay tuned for more information! 23 Questions Domain 4: Local Dental Pilot Programs For information on the project or to submit questions/concerns regarding DTI, send email to: DTI@dhcs.ca.gov DHCS Webpage dedicated to DTI publications and public information: http://www.dhcs.ca.gov/provgovpart/pages/dti.aspx Medi-Cal Dental Services Division: dental@dhcs.ca.gov 24 12