California Medi-Cal Dental Program. Denti-Cal FAQs. Elimination of Most Adult Dental Services Beneficiary Frequently Asked Questions (FAQs)
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1 California Medi-Cal Dental Program Denti-Cal FAQs Elimination of Most Adult Dental Services Beneficiary Frequently Asked Questions (FAQs) Why 1. Why is the state eliminating the adult program? State law (Welfare and Institutions Code section ) eliminated most adult dental services as a Medi-Cal benefit. The federal government considers most adult dental services optional Medicaid benefits. (In California, the Medicaid program is called Medi- Cal and the dental program is called Denti-Cal.) The State decides which optional Medi- Cal benefits to cover. The State decided to cut adult dental services due to the budget crisis. Other Medi-Cal services that are mandatory under federal law will continue to be covered. When 2. When are most of the adult dental services going to be cut? Most adult dental services will be cut beginning July 1, When are beneficiaries going to be notified of these changes? We anticipate notification in mid-june Who/What 4. Who can still receive adult dental services under the Denti-Cal program? Adult dental services for the following people will continue as benefits under the Denti-Cal program: a. Children or young adults who are under 21 years of age with full scope Medi-Cal, and who are EPSDT eligible. b. Women who are pregnant will be eligible to receive pregnancy related services or services to treat a condition that may cause a problem in pregnancy. These are services such as exams, cleanings and gum treatments. c. People who live in certain licensed Skilled Nursing Facilities (SNFs) or certain licensed Intermediate Care Facilities (ICFs).
2 5. Are there any adult dental services available for people who do not meet the exceptions above? All other beneficiaries not otherwise exempt are only eligible for limited dental services for the relief of pain and infection such as tooth removal. These dental services are medical and surgical services provided by a doctor of dental medicine or dental surgery, which, if provided by a doctor, would be considered physician services, and which services may be provided by either a doctor or a dentist in this state. Federal law requires the provision of these services. 6. Are beneficiaries who are patients of a Federally Qualified Health Center (FQHC) or Rural Health Center (RHC) affected? Yes. All other beneficiaries not otherwise exempt are only eligible for limited dental services for the relief of pain and infection such as tooth removal. These dental services are medical and surgical services provided by a doctor of dental medicine or dental surgery, which, if provided by a doctor, would be considered physician services, and which services may be provided by either a doctor or a dentist in this state. Federal law requires the provision of these services. Please call your FQHC/RHC provider for additional assistance. 7. Who is affected by these adult dental services cuts? Any beneficiary age 21 and older who is not pregnant or does not live in a licensed Skilled Nursing Facility (SNF) or licensed Intermediate Care Facility (ICF). 8. Are all adult dental benefits being removed? No. Most services are eliminated such as cleanings, exams, fillings, gum treatments, crowns, root canals and dentures. Certain services for the relief of pain and infection remain available such as tooth removal. 9. What dental services will still be covered for adults? Limited dental services for the relief of pain and infection will still be covered such as tooth removal. 10. Will disabled beneficiaries over the age of 21 continue to be covered? There are no exemptions for disabled beneficiaries. Certain dental services may be available if the beneficiary is receiving services through the Genetically Handicapped Persons Program (GHPP). To find out whether you qualify for GHPP, please call the GHPP office at or you may go to the GHPP Web site at Will the state make exceptions for people on Social Security Income (SSI) on or after July 1, 2009? No, the law did not make an exception for people on SSI. Page 2 Denti-Cal FAQs - Beneficiary
3 12. Can I still go to my dentist? The Denti-Cal program will no longer cover most adult dental services on or after 7/1/09. You will have to pay for those services which are no longer covered. 13. What can I do if the adult dental services I need are no longer covered (i.e. fillings, crowns, root canals, dentures)? You can: 1) Pay for your services 2) Make arrangements with the dentist to pay over time 3) Find a community clinic that charges based on your ability to pay (see Will the $1,800 annual cap on adult dental services still be in effect on July 1, 2009? Yes. 15. What can I do if I have a severe tooth ache? Call your dentist. If you do not have a dentist, call the Beneficiary Customer Service toll free line, Will there be any exceptions for medical conditions on or after July 1, 2009? No. 17. Will dental x-rays be covered on or after July 1, 2009? Dental x-rays will only be covered when the x-ray is related to a treatment which is still a covered adult dental service. 18. If dental work paid for by Denti-Cal needs repair or replacement, will this be covered? No. Repairs or replacements for eliminated adult dental services such as dentures and crowns will not be covered on or after July 1, If I am in pain, do I have to go to the emergency room? No. You can see a Denti-Cal dentist who can provide and receive payment for services needed to relieve pain and infection. 20. My doctor told me I needed to have some dental work completed before I could get a medical procedure. Will I have to pay out-of-pocket? Beneficiaries may receive dental services that are necessary in order to undergo a covered medical service. Have your dentist send a Treatment Authorization Request (TAR) to Denti-Cal with written documentation from your doctor stating why the dental services are necessary before you have the medical service. Beneficiaries covered by a managed care dental plan will have to work with their managed care dental plan. Denti-Cal FAQs - Beneficiary Page 3
4 Completion of Treatment for those who turn I was being treated by my dentist before I turned 21. Will I be able to complete the dental treatment after I turn 21? Yes. Beneficiaries who are under 21 years of age and whose course of treatment is scheduled to continue after he/she turns 21 years of age will be able to complete the treatment as long as the dentist has an authorization from Denti-Cal for the services before the beneficiary turns 21 years of age. All orthodontic services must be completed before the beneficiary turns 21. Certain dental services that you receive while you are with California Children Services (CCS) may stop when you reach 21 years. Make sure that the dental services you are getting from CCS have been completed before you turn 21 years. Orders for lifetime treatment will not be considered. Completion of Treatment for Services on or after 7/1/ I was in the middle of treatment by my dentist before July 1, Will I be able to complete the dental treatment on or after July 1, 2009? Yes, if your dentist has an approval for treatment before July 1, Please call your dentist to confirm the details. SNF/ICF 23. Are adults living in residential care facilities exempt? No. 24. My mother is in a nursing home. Is her dental care still covered? That depends on the type of facility she lives in. Adults living in certain licensed Skilled Nursing Facilities (SNFs) or certain licensed Intermediate Care Facilities (ICFs) will be exempt from the adult dental cuts. Please contact the Beneficiary Service Center at to verify whether a facility is exempt. 25. What happens to the elderly beneficiaries who live with their children and not in facilities? They will be subject to the same cuts in benefits as other adults. Pregnant Beneficiaries 26. What types of dental services will be allowed for pregnant beneficiaries? Women who are pregnant will be eligible to receive pregnancy related services or services to treat a condition that may cause a problem in pregnancy. These are services such as exams, cleanings and gum treatments. Page 4 Denti-Cal FAQs - Beneficiary
5 Managed Care 27. I am in a Denti-Cal Managed Care Dental Plan. Are my dental services going to be cut on July 1, 2009? Yes, the same adult dental services cuts will affect both fee-for-service and managed care dental providers. If you have questions about your Managed Care Plan, contact your plan s member help line. The phone number is located on your plan ID card. Fair Hearings 28. Are fair hearing decisions pursuant to an Administrative Law Judge or DHCS agreement to rescind the denial and approve the requested service still valid on or after July 1, 2009? Yes, as long as you complete the service(s) within the authorization period of 180 days. Denti-Cal FAQs - Beneficiary Page 5
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COMMITMENT INTEGRITY LEADERSHIP. California Department of Health Care Services. December 2014
California Department of Health Care Services Weaknesses in Its Medi Cal Dental Program Limit Children s Access to Dental Care Report 2013 125 COMMITMENT INTEGRITY LEADERSHIP The first five copies of each