Dental Benefit Plans

CDA-sponsored legislation that further increases dental plan transparency became law on Jan. 1. AB 954 requires dental plans to be more transparent about the leasing of dental networks. The new law will reduce patient and dentist confusion caused by the increasing number of plans leasing their networks to other payers, many times unbeknownst to the enrollee or contracted dentist(s). The law took effect for contracts entered into on or after Jan. 1, 2020.

Health care providers can expect to see major revisions to the Medi-Cal program over the next couple of years as a result of a new initiative by the Department of Health Care Services. Released in late October, the California Advancing and Innovating Medi-Cal (CalAIM) proposal will implement “broader delivery system, program and payment reform across the Medi-Cal Program,” according to the proposal summary.

CDA Practice Support receives hundreds of calls each year concerning the coordination of benefits when a patient has more than one dental plan for coverage. Standard COB allows secondary dental plans to pay up to 100% of the covered service, i.e., the primary plan pays the service at 80%, and the secondary could pick up the remaining 20%. Here, CDA’s dental benefits analyst covers the COB basics and answers common questions members have about COB.

Today, many dental benefit plans use auto-adjudication to process a high number of their claims. While auto-adjudication can speed up claim processing, if an office is not aware that this type of technology is being used, the office can be confused and frustrated by processing errors as the result of manual claims submission. The following three examples illustrate how a plan might use auto-adjudication and how that process might affect dental reimbursement.

Improvements to the Medi-Cal Dental program continue with new options for dentists who treat Medi-Cal members, including the ability to provide fluoride treatment and fluoride varnish as a benefit once every four months for patients under age 6. The increase in the benefit periodicity underscores the state’s commitment to regular preventive oral health visits for young children in California.

Adding or dropping a contract with a dental benefit plan is a personal business decision. There is no “one size fits all” in these types of business decisions, as what might work for one dentist might not work for another. You may be asking yourself how a dentist can make a good decision about adding or dropping a dental plan/network participation, but there is one key element in each success story.

Congratulations — the dental plan paid the claim! Or did they? Confirmation that your claim has been processed comes in two forms: payment and/or an explanation of benefits. An EOB is sent to the patient and/or dental office as a receipt of services provided. Unfortunately, dental plans do not have standardized formats for these documents, which is why it’s necessary for an office to read the EOB completely.

Marc Bernardo, DMD, MPH, and Michelle Galeon, DMD, are among the first recipients of a new grant funded by Proposition 56, a voter-approved tobacco tax that CDA and other health care organizations sponsored in 2016. The grant program awarded $10 million in debt relief to 38 dentists (up to $300,000 each) in exchange for the dentists maintaining a 30% or more Medi-Cal patient caseload for five years.

The Department of Health Care Service’s new program designed to expand access to care for Medi-Cal patients has awarded $10.5 million to 40 dentists to pay student loan debt. Approximately 1,300 health care providers, including 350 dentists, applied to the CalHealthCares program, which offers up to $300,000 in debt relief in exchange for meeting certain criteria.

As part of the finalized 2019-20 California state budget, the Legislature and Gov. Gavin Newsom approved a continuation of supplemental Medi-Cal provider rates, including significant dollars for dentists serving Medi-Cal patients. An additional $20 million was dedicated to dentists through a recently launched student loan repayment program.

What started the legal action that led to this settlement? CDA filed the legal action in August 2013 after learning…

A San Francisco Superior Court judge has granted final approval of the $65 million amended settlement agreement between Delta Dental…