Access Issues in Denti-Cal Exist for All Patients

Patients have struggled to access care through Denti-Cal, California’s dental benefit in Medi-Cal.

• Only 44 percent of children enrolled in Denti-Cal saw a dentist in 2013.[i]

• California removed the adult dental benefit in Denti-Cal in 2009, partially restored the benefit in 2014, and fully restored the benefit in 2018. However, only 26 percent of eligible California adults with fee-for-service (FFS) Denti-Cal coverage saw a dentist in 2014.[ii]

• Denti-Cal eligible patients seeking dental care frequently have difficulty finding places to use their benefits because many California dentists do not participate in the program, citing low reimbursement and overly burdensome administrative requirements.[iii]

• According to current data from the Department of Health Care Services, there are no Denti-Cal participating dentists in 13 of the state’s 58 counties, primarily in rural Northern California. In seven counties, there is only one participating dentist. In San Francisco, there are only 20 dentists and orthodontists to serve roughly 150,000 Medi-Cal enrollees.[iv]

Patients with Special Needs Face Higher Barriers to Care

Patients who have chronic medical, mental, behavioral, or developmental conditions and disabilities who may require special services and care face the highest barriers in accessing dental care they need.

• Patients with special needs often have higher oral health needs. For example, one study of approximately 4,700 adults with intellectual and developmental disabilities found that 32.2 percent of the population had untreated dental caries, 80.3 percent were diagnosed with severe gum infection, and 10.9 percent had missing teeth.[v] These patients also often forgo care, resulting in later stage complications.

• Patients with special needs often require providers spend additional time and furnish additional resources, resulting in higher associated costs, and may require multiple visits to complete procedures. In the same study cited above, researchers found that nearly a quarter of the patients had only a limited ability to accept any dental intervention without the application of advanced behavior management techniques, and nearly 40 percent required some form of behavioral assistance to receive dental treatment.[vi]

• Denti-Cal’s standardized policies and payments, based on a healthier population, don’t acknowledge these additional costs of caring for persons with special needs and inhibit providers’ ability to receive proper payment for their care.

SB 1464 Is a First Step to Increasing Access to Care for Patients with Special Needs

The goal of this bill is to expand access for children and adults who have chronic medical, mental, behavioral, or developmental conditions and disabilities which complicate their dental care by ensuring providers have more adequate compensation to treat these patients. The bill proposes that:

• DHCS will develop a mechanism to identify individuals with disabilities and conditions that complicate their dental care or require additional expertise and action.

• For these eligible patients, DHCS will determine how dental providers may be reimbursed for the extra time and resources they spend on their care.

• DHCS will establish the payment amount.