Accessing Dental Care through the Denti-Cal Program

Contents:

• Administration
• Eligibility
• Services
• References for qualifying orthodontic services
• Appeals Process

From Medi-Cal Summary, with materials developed by Manjusha Kuldarni, National Health Law Program for the Health Consumer Alliance, 10/2002 www.healthconsumer.org

The primary objective of the Denti-Cal Program is to create a better dental care system and increase quality of services available to those individuals and families who rely on Medi-Cal to meet their health care needs.

Administration

Denti-Cal is the dental care segment of the Medi-Cal program.

Denti-Cal is administered by a private managed care plan, Delta Dental.

Delta Dental's primary function is to process claims and treatment authorization request (TARs) submitted by providers for dental services performed for Medi-Cal beneficiaries.

The most recent contract between California Department of Health Services (DHS) and Delta Dental was signed in 1998.

Eligibility, administration and scope of services is governed by Welfare and Institution Code 14000 et seq. And Title 10 and Title 22 of the California Code of Regulations.

Additional guidance about the program is provided in the Denti-Cal Provider Manual.

Eligibility

Individuals who are enrolled in the Medi-Cal Program are eligible to receive dental services provided by Denti-Cal.

Eligibility is verified through presentation of a Beneficiary Identification Card, known as a BIC card.

Certain limitations in access to dental services may apply to the following beneficiaries:

Upon verifying eligibility in Medi-Cal, a provider cannot bill a beneficiary for any part of the charge for a Medi-Cal covered service, except to collect copayments or share of cost. Providers can request payment of share of cost.

Additionally, providers can input information about incurred medical expenses into the AEVS system (Automated Eligibility Verification System), which can help a beneficiary satisfy his/her share of cost obligation.

Services

Generally, Denti-Cal covers inpatient and outpatient services "which are reasonable and necessary for the prevention, diagnosis, and treatment of dental disease, injury or defect."

A number of dental services, including emergency and diagnostic services, including examinations, radiographs, biopsies and dental prophylaxis, are covered without prior authorization.

Denti-Cal services are provided through fee-for-service as well as managed care arrangements.

In the fee-for-service system, beneficiaries can access any dental provider who participates in Medi-Cal in their geographic area.

In managed care, beneficiaries are restricted to those providers participating in the dental plan.

Additionally, in the fee-for-service system, approval of some services must be sought through a Treatment Authorization Request (TAR). In managed, care approval of certain services is provided by the health plan through its pre-authorization process.

Some services, such as cosmetic procedures, experimental procedures that increase vertical dimension or restore occlusion, are excluded from coverage by Denti-Cal.

References for qualifying orthodontic services

CAL. CODE REGS. Title 22, Section 51307(b). Other covered services, which do not require prior authorization, include … occlusal adjustment …

CAL CODE REGS. Title 22 Section 51307(d). Additionally, the following services are not covered: orthodontic services, except for handicapping malocclusion and cleft palate deformities … except when necessary for obtaining employment or medical conditions which preclude use of removable dental prostheses.

Denti-Cal coverage of orthodontia is complicated and confusing.

DHS uses the modified Handicapping Labio-Lingual Deviation (HLD) Index to determine whether orthodontics will be covered for children with handicapping malocclusions. While DHS requires a score of 26 or higher on the HLD index in order to qualify for the treatment, children with scores below 26 points should be able to obtain orthodontic treatment if they meet the EPSDT standard.

See Denti-Cal Provider Manual, DHS, Orthodontic Services for Handicapping Malocclusion and Early and Periodic Screening, Diagnosis and Treatment (EPSDT), p. 4-45 - 4-46.

Appeals Process

If Denti-Cal denies coverage of a dental service to which a beneficiary believes he/she is entitled, she can appeal the denial, just as she would in Medi-Cal.

Beneficiaries can challenge denials by requesting a fair hearing within ninety days from the date of the notice of action denying services. They can request a fair hearing by completing and faxing or mailing the reverse side of the Denti-Cal notice of action or calling (800) 743-8525.

If the beneficiary no longer had the notice of action or never received one, she can mail a letter to the Office of the Chief Administrative Law Judge. The letter should include the beneficiary's name, Medi-Cal number or Social Security number, address and phone number as well as a general statement about why the beneficiary is requesting a fair hearing or filing a grievance, or both.

Finally, if beneficiaries pursue a grievance, they should be aware of the fact that the 90-day window to request a fair hearing is not tolled.

For that reason, advocates are encouraged to file a grievance and a fair hearing simultaneously. In some instances, filing a fair hearing may encourage the plan to resolve the dispute. If the beneficiary receives a favorable outcome on the grievance, he/she may withdraw his/her fair hearing request.

Next: California Children's Services (CCS)