Some low-income children in Sacramento County who have tried but failed to get dental care would have an escape route under a bill awaiting action by the governor.
Currently, dental managed care is mandatory for the roughly 100,000 Sacramento County children on Medi-Cal. But the program has one of the state's worst access records and has left many children waiting months for treatment for painful, rotted or broken teeth.
The measure by Senate President Pro Tem Darrell Steinberg, D-Sacramento would allow some children who, despite trying, haven't been able to see a dentist within four weeks for routine appointments and 24 hours for emergencies to switch to a "fee-for-service" program that offers more flexibility.
It also creates new accountability and reporting requirements for dental plans participating in Medi-Cal managed care programs in both Sacramento and Los Angeles counties.
"These are key steps to resolve the problems we've seen with children's managed dental care in Sacramento," said Steinberg spokesman Mark Hedlund. "We have every intention to stay on top of this issue."
In fiscal year 2010-2011, about 31 percent of Sacramento County children with Medi-Cal saw a dentist, compared with nearly half of children on Medi-Cal statewide.
A CHCF Center for Health Reporting story published in February in The Bee sparked Steinberg to seek the changes.
Sacramento County operates the state's only mandatory dental managed care model under Medi-Cal. Dental managed care is voluntary in Los Angeles County.
Under managed care, the state pays private dental plans a monthly fee currently about $11.50 for each Medi-Cal child assigned to them. The fee is paid regardless of whether the child actually sees a dentist.
The plans pay clinics and dentists a lesser amount per month to provide the care.
The rest of the state uses the fee-for-service model, allowing dentists to bill Medi-Cal for services, which results in a substantially higher reimbursement.
The bill, which the Legislature approved earlier this month as part of this year's budget negotiations, would create a process through which Sacramento children can apply to get out of dental managed care. It would take effect July 1 if Brown signs it.
Here's how it would work: If a child is unable to access dental services within certain time frames which depend on the kind of appointment the child needs his or her parents can contact the state Department of Health Care Services (DHCS) by mail, phone or fax. Within five days of making contact with the family, the department will attempt to set up an appointment for the child.
If the department cannot set up an appointment within a reasonable time frame to be determined on a case-by-case basis, the department said the child can move to fee-for-service.
If it succeeds, the child will stay in managed care.
The department will hire two new staff members to handle the additional workload, said DHCS spokesman Norman Williams.
"We are continuing our work to improve the managed care dental system," he said.
Originally, Steinberg and children's advocates had called for making dental managed care voluntary in Sacramento County, so parents could choose managed care or fee-for-service without having to apply for an exemption.
"Yes, we proposed to the administration to move Sacramento managed dental care to a voluntary system, and we preferred that route," Hedlund said.
But "politics is always the art of compromise," he said, adding that Steinberg is hopeful that this plan will "meet the goal of improving children's dental health."
Debra Payne, health and dental program planner at First 5 Sacramento, said she has "guarded optimism" that the compromise will work.
If it doesn't, she said, an oversight committee made up of dentists and children's advocates likely will propose that the program become voluntary.
"I just want to be sure that the families will get these services within the time frames already outlined," she said. "This will require the dental plans to be more responsive to the families and to ensure that the dental plans are meeting their contract terms."
The measure requires additional reporting requirements of the department and dental plans. Dental plans also will have to meet performance measures, such as benchmarks on annual dental visits and whether the plan has an adequate network of dentists, or they will face financial penalties, Williams said.
Liberty Dental Plan supports the bill and exemption process for Sacramento County children, said John Carvelli, executive vice president.
This month, his plan took on about 16,000 Medi-Cal members in Sacramento and Los Angeles counties who belonged to another dental plan, Community Dental Services.
Community Dental Services ceased operations in response to a state audit.
The renewed attention on dental managed care and outreach efforts by the plan have been paying off, he said.
The number of the plan's Sacramento County Medi-Cal patients who saw a dentist in the first three months of this year jumped 14 percent over the same period last year, a percentage that Carvelli called "significant in our industry."
"We're already seeing improvement, and there's going to be more," he said.