Dental Transformation Initiative & More · Presentation Outline 1) Brief Medi-Cal Dental Program...

Dental Transformation Initiative& More

Alani Jackson, MPAChief, Medi-Cal Dental Services Division

November 2, 20171

Presentation Outline

1) Brief Medi-Cal Dental Program Overview

2) 2020 Waiver: Dental TransformationInitiative

3) Adult Dental Restoration

4) Questions

11/02/2017 2

Medi-Cal Dental Services Overview

Total Medi-Cal population – Approximately 13.9 million beneficiaries

Total dental program budget – Approximately $1.4 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)

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Medi-Cal Dental Services 2016 Utilization Rates

2016 Medi-Cal Dental Utilization Rates

Medi-Cal beneficiaries who were continuously enrolled in same plan for at least 3 months, had full scope benefits and no share of cost

Performance Measures Plan Beneficiaries ages <21 Beneficiaries ages 21+Dental Offices

SNCs Total Dental Offices

SNCs Total

Annual Dental Visits-Beneficiaries who had at least one (1) dental visit during the measurement period.

DMC 29.3% 0.2% 29.5% 15.7%* 0.2%* 15.8%*

FFS 38.5% 6.6% 45.1% 16.3% 4.5% 20.8%

Preventive-Beneficiaries who received any preventive dental service during the measurement period.

DMC 23.2% 5.7%

FFS 35.5% 8.2%

Exams/Oral Health-Beneficiaries who received a comprehensive or periodic oral health evaluation or, for Beneficiaries under 3 years of age, who received an oral evaluation and counseling with the primary care giver during the measurement period.

DMC 23.4% 10.9%

FFS 35.2% 11.1%

Dental Treatments-Beneficiaries who received any dental treatment service during the measurement period.

DMC 14.1% 9.2%

FFS 19.0% 10.3%

Data as of Aug 2017*Percentage does not add up due to rounding

Medi-Cal 2020 Overview

CMS approval

for renewal on

December 30, 2015

Effective January 1,

2016 through

December 31, 2020

$6.2 billion total initial

federal funding over 5 years

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Program Period & Funding Overview

DTI01/01/16

–12/31/20

$740M

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Dental Transformation Initiative:Domain Areas

Domain 1: Increase Preventive Services Utilization for Children

Domain 2: Caries Risk Assessment and Disease Management

Domain 3: Increase Continuity of Care

Domain 4: Local Dental Pilot Programs (LDPPs)

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Dental Transformation Initiative

Domain GoalIncrease statewide proportion of children ages 1-20 enrolled in Medi-Cal who receive a preventive dental service by 10 percentage points over a five-year period.

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PriorityData 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.

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Priority• Tooth decay remains one of the most

preventable common chronic diseases of childhood.Tooth decay causes significant pain, loss of school days and may lead to infections and even death.

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Who can participate in this Domain?Medi-Cal Dental Fee-For-Service (FFS)Dental Managed Care (DMC) Safety Net Clinics (SNC)

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Incentive Payment CalculationPayments are made to service office locations (SOL) that meet their annual benchmark for increased preventive services.

Benchmark is based on SOL’s preventive services to Medi-Cal beneficiaries during the baseline calendar year (CY) 2014.

SOL with 2% point increase – 75% of SMASOL with 1-1.99% point increase – 37.5% of SMA

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Domain 1: Increase Preventive Service Utilization for ChildrenDomain 1: Increase Preventive Services Utilization for Children

Frequency of PaymentIncentive payments paid on a semi-annual basisFirst incentive payments paid in January 2017, Second in July 2017Next payment January 2018

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SNC Providers submitting DTI Domain 1 encounter data for Program Year 1 (calendar year 2016) via the proprietary paper form, must submit their encounters for 2016 dates of service to Delta Dental no later than December 8, 2017 to be eligible for the final payment for program year 1 on January 31, 2018.

SNC Providers submitting DTI Domain 1 encounter data for Program Year 1 (calendar year 2016) via the Electronic Data Interchange (EDI) must submit or instruct their clearinghouse to submit their 2016 encounter data to Delta Dental by December 23, 2017 to be eligible for the final payment for program year 1 on January 31, 2018.

Note: EDI testing with Delta Dental is required prior to Program Year 1 Domain 1 encounter data submission. Please note the final date to complete EDI testing for Program Year 1 is November 17, 2017. 14

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http://www.denti-cal.ca.gov/provsrvcs/forms/dc_217_SNC_paper_encounter_form.pdf


Domain 1: Increase Preventive Service Utilization for ChildrenDomain 1: Increase Preventive Services Utilization for Children

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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

Dental Transformation InitiativeDomain 1: Increase Preventive Services Utilization for Children

Top performing Indian Health Programs:1. American Indian Health and Services2. Rolling Hills Clinic 3. Indian Health Council4. Indian Health Center of Santa Clara5. United Indian Health Services, Inc.-

Potawot Health Village16

Dental Transformation InitiativeDomain 2: Caries Risk Assessment and Disease Management PilotDomain 2: Caries Risk Assessment and Disease Management

Domain GoalsDiagnose Early Childhood Caries (ECC) by utilizing Caries Risk Assessments (CRA) to treat it as a chronic disease.Introduce a model that proactively prevents and mitigates oral disease through the delivery of preventative services in lieu of more invasive and costly procedures (restorative services).

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Dental Transformation InitiativeDomain 2:Caries Risk Assessment and Disease Management PilotDomain 2: Caries Risk Assessment and Disease Management

Domain GoalsIdentify the effectiveness of CRA and treatment plans for children ages 6 and under.

Treatment plans are prescribed based on caries risk level and include: CRA procedure bundle (CRA and globally includes nutritionalcounseling and motivational interviewing), topical fluoride procedures, prophylaxis andexams.

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DHCS Caries Risk Assessment ToolAdaptation of a nationally recognized caries risk assessment tool.Designed for the DTI CRA and DiseaseManagement Pilot.Provides dentists with a form to gather information for classifying children into high, moderate or low caries risk categories.

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PriorityData 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.

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Dental Transformation InitiativeEarly 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

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Dental Transformation InitiativeDomain 2: Caries Risk Assessment and Disease Management Pilot


Pilot Counties:1. Glenn 2. Humboldt3. Inyo4. Kings5. Lassen6. Mendocino

7. Plumas8. Sacramento9. Sierra10.Tulare11.Yuba

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Dental Transformation Initiative 2: Caries Risk Assessment and Disease Management Domain

Provider Participation Process

Dentists can opt-in by completing an attestation and awebinar training program. A certificate of completionwill 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 forcourse completion.

No Cost to CDA members/non-members.

2 CE awarded.

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http://www.dhcs.ca.gov/provgovpart/Documents/Domain%202%20Provider%20Opt-In%20Attestation.pdf

http://www.cda.org/TYKE

Dental Transformation InitiativeDomain 2: Caries Risk Assessment and Disease Management Pilot

To qualify for Domain 2 incentive payment, providers must submit the following documentation:

Certificate of Completion of the DHCS approved CRA Training.Completed Domain 2 CRA Provider Opt-In Attestation Form.Report the results of the CRA on the claim.


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Domain 2:Caries Risk Assessment and Disease Management

SNCs will be required to file claims using the DTI Encounter Form found on the Denti-Cal website, or electronically via Electronic Data Interchange (EDI).

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http://www.denti-cal.ca.gov/provsrvcs/forms/dc_217_SNC_paper_encounter_form.pdf



CriteriaTreatment plans and associated procedures willbe carried out as follows, over a 12 month period:

“High Risk” children will be authorized to visit 4times per year.“Moderate Risk” children will be authorized tovisit 3 times per year.“Low Risk” children will be authorized to visit 2times per year (current benefit).

The increase in frequencies take effect once a CRAprocedure bundle is in a beneficiary’s history.

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Dental Transformation InitiativeDomain 2: Caries Risk Assessment and Disease Domain 2: Caries Risk Assessment and Disease Management

The CRA procedure bundle consists of three CDT codes which must be performed on the same date of service and submitted together on oneclaim.

1. Caries Risk Assessment ($15.00)D0601 Low Risk (twice a year)D0602 Medium Risk (three times a year)D0603 High Risk (four times a year)

2. Nutritional Counseling ($46.00)D1310

3. Motivational Interview ($65.00)D9993

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In addition to the CRA procedure bundle, for highrisk patients, interim caries arresting medicament(Silver Diamine Fluoride) may be performed asneeded but is reimbursed no more than twice peryear.

D1354 ($35.00) a benefit every six months for a whole mouth treatment.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.

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Incentive PaymentsIncentive payments will be made to providersfor successful completion of a CRA procedurebundle.CRA procedure bundles will need to besubmitted regularly, per risk level, in order toremain eligible for increased frequencypayments.Improvement in “elevated risk” levels will beevaluated.

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As of October 27, 2017:Total Payment: $1,038,064294 providers completed TYKE training114 providers participating in 11 countiesOutreach Efforts: collaboration with professional societies, FI, and DMCInyo County had the first successful clinic payment – Toiyabe Indian Health Project

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Domain GoalIncrease continuity of care for beneficiaries ages 20 and under for 2, 3, 4, 5, and 6 year continuousperiods.Claims data will determine the number of beneficiaries who received an examination each year from the same service office location for two (2), three (3), four (4), five (5) and six (6) year continuous periods.

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PriorityToo many people mistakenly believe that theirchildren need to see a dentist only if they are in painor think something is wrong.Continuity of care is working with the same practiceand same dentist over time to establish a dentalhome, and to ensure that treatment continues in theright direction and future potential problems can beaddressed before they become more serious.

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Domain 3: Continuity of Care

1. Alameda2. Del Norte3. El Dorado4. Fresno5. Kern6. Madera7. Marin8. Modoc9. Nevada

10. Placer11. Riverside12. San Luis Obispo13. Santa Cruz14. Shasta15. Sonoma16. Stanislaus17. Yolo

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Domain 3: Continuity of CareDomain 3: Increase Continuity of Care

Frequency of PaymentFlat rate incentive payment to SOLs annually that have maintained continuity of care through providing qualifying examinations (D0120, D0150 or D0145) to their enrolled beneficiaries, age twenty (20) and under. Separate payments for two (2), three (3), four (4), five (5) and six (6) year continuous periods.Annual Incentive payment is applicable in any of the demonstration years if continuity of care is provided during the term of the waiver.

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Domain 3: Continuity of CareDomain 3: Increase Continuity of Care

First Annual Payment in June 30, 2017 was for $9.4 Million

FFS $9.2M/ 684 SOLSNC $184,320/ 8 SOL

Next Annual Payment – June 30, 2018

Opt-In Form for Clinics is posted on the DTI Domain 3 webpage, and will be updated to reflect Program Year 2 information.

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Domai n 4

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Domain Goal• Local Dental Pilot Program (LDPP) will address one or

more of the three domains through alternativeprograms, potentially using strategies focused on ruralareas including local case management initiatives andeducation partnerships.

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15 LDPPs were selected (11 have executed contracts)Evaluation of their success will occur in the third year.


Domain 4: Local Dental Pilot Programs (LDPPs)

15 Approved Projects1. Alameda County2. California Rural Indian Health Board, Inc.3. California State University, Los Angeles4. First 5 Kern5. First 5 San Joaquin6. First 5 Riverside (includes San Bernardino County)7. Fresno County8. Humboldt County

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Domain 4: Local Dental Pilot ProgramDomain 4: Local Dental Pilot Programs (LDPPs)

15 Approved Projects cont. 9. Northern Valley Sierra Consortium (Butte, Nevada,

Plumas, Sutter, and Yuba Counties)10. Orange County11. Sacramento County (includes Amador County)12. San Luis Obispo County13. San Francisco City and County Department of Public

Health14. Sonoma County15. University of California, Los Angeles

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Domain 4: Local Dental Pilot ProgramDomain 4: Local Dental Pilot Programs (LDPPs)California Rural Indian Health Board, Inc.

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For information on the project orto submit questions/concernsregarding DTI, send email to:[email protected]

DHCS Webpage dedicated to DTI publications and public information: http://www.dhcs.ca.gov/provgovpart/Pages/DTI.aspx

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mailto:[email protected]

http://www.dhcs.ca.gov/provgovpart/Pages/DTI.aspx

Restoration of Adult Dental Services

AB113 – Contingent on Federal ApprovalEffective Date: January 1, 2018Restoring all optional adult dental benefits eliminated in 2009 and not restored in 2014Tribal notice was posted on October 5, 2017: http://www.dhcs.ca.gov/services/rural/Documents/SPA17-027_and_SPA_17-041_w_Memo.pdfStay tuned for more information!

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http://www.dhcs.ca.gov/services/rural/Documents/SPA17-027_and_SPA_17-041_w_Memo.pdf

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Medi-Cal Dental Services Division: [email protected]

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mailto:[email protected]

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