Oral Well being for Older Adults in California

About This Information

This Information is designed for advocates and people who present help to low-income older adults and other people with disabilities to raised join their shoppers to high quality oral well being care. The primary portion of this Information focuses on why oral well being issues and offers a abstract of the present state of oral well being for older adults in California. The second portion of this Information offers an summary of medical insurance protection choices for oral well being together with an in depth abstract of the Medi-Cal Dental program. The third portion of this Information opinions distinctive limitations encountered by sure sub-populations of older adults, together with people dually enrolled in Medicare and Medi-Cal and people residing in institutional settings like nursing services. The Information ends with an summary of therapy options for individuals who shouldn’t have medical insurance. We even have included assets and supplemental supplies within the Appendices to help with advocacy.

Justice in Getting old strives to make the data on this Information as correct as attainable as of the publication date. Nevertheless, applications serving this inhabitants are at all times evolving. To get essentially the most up-to-date data on oral well being for older adults, join alerts.

Acknowledgments

The Information is funded partly by grants from Cal Wellness and the Delta Dental Basis. We’d additionally wish to thank our colleagues on the Heart for Medicare Advocacy and Neighborhood Authorized Companies for his or her vital contributions to the unique Information revealed in 2018.

Desk of Contents

Introduction: Why Oral Well being Issues

Oral well being is an important side of general well being for individuals of all ages, however particularly for older adults whose oral well being situations compound over the lifetime and place them at elevated danger for a lot of oral illnesses, together with tooth decay, dental root decay, gum illness, and oral most cancers.^[1] Much like older adults throughout the nation, older adults in California expertise vital challenges when trying to entry oral healthcare.

California and Nationwide Views: The State of Oral Well being for Older Adults

The state of oral well being for older adults in California is notably poor. Almost one third of adults 65 and over have misplaced six or extra everlasting enamel, and practically 9 p.c of older adults aged 65-74 have full tooth loss.^[2] Tooth loss in nursing services is regrettably a lot larger. Over one third of nursing facility residents in California report full tooth loss and one-third of that group shouldn’t have any dentures.^[3] In reality, the oral well being of people residing in California’s expert nursing services is considerably poorer than these residing in the neighborhood on all measures together with untreated decay, means to chew, and gum well being.^[4] Equally, people with disabilities, significantly people with developmental disabilities, expertise poorer oral well being and limitations to therapy than individuals with out disabilities.^[5]

Whereas intersectional information on oral well being outcomes based mostly on age and race will not be obtainable in California, nationwide information reveals stark disparities. For instance, nationwide, 17% of older adults haven’t any remaining pure enamel. Whereas that price has been steadily lowering lately, the proportion of Black older adults with full tooth loss is about 30%—nearly double the nationwide common—with minimal change over the previous decade.^[6] Nationwide information additionally exhibits that Black, American Indian, Alaska Natives (AI/AN), and Mexican-American older adults all have larger charges of untreated tooth decay and tooth loss, in addition to poorer entry to preventive companies than white older adults.^[7]

Nationwide information for nursing services additionally exhibits oral healthcare disparities are wider for decrease earnings, rural and residents of colour as in comparison with white residents. For instance, AI/AN residents have been 34% extra possible and Black residents 16% extra prone to haven’t any pure enamel in comparison with white residents. Residents in rural nursing services are 70% extra prone to expertise dental issues than residents of city nursing services.^[8]

The Affect of Poor Dental Care on the Well being of Older Adults

There’s settlement amongst dental consultants that poor oral well being has a considerable affect on the overall well being of older adults. Tooth decay and related mouth ache result in weight reduction and poor diet, and exacerbate continual situations like diabetes and coronary heart illness—situations that people usually tend to purchase later in life.^[11] Poor oral well being additionally results in elevated infections, which analysis associates with larger danger for coronary heart and lung illness, experiencing a stroke, having diabetic problems, and may end up in aspiration pneumonia, adopted by hospitalization and loss of life – significantly amongst nursing facility residents.^[12][13][14] Additional, for older adults with weakened immune programs, oral infections can change into continual.^[15]

Most not too long ago, oral well being has been linked to Alzheimer’s and dementia.^[16] Analysis exhibits that poor oral well being will increase the chance of growing dementia and, conversely, people with dementia usually tend to have poor oral well being.^[17]

Poor oral well being care additionally has a major affect on general high quality of life. For instance, mouth ache disrupts sleep, growing the chance for melancholy and insomnia.^[18] Ongoing ache related to untreated oral well being illness will increase the chance that opioids will probably be prescribed and the prospect of abuse.^[19]

Communities of colour and people residing in poverty are additionally about twice as possible as the overall older grownup inhabitants to report that poor oral well being negatively impacts their satisfaction with life.^[20] They report back to a better extent oral ache, meals avoidance, and self-consciousness or embarrassment due to their mouth, enamel, or dentures.^[21]

Oral well being and general well being are linked. When the physique is wholesome, the mouth is extra prone to be wholesome, too. And, vice versa.

Oral well being and general well being are linked. When the physique is wholesome, the mouth is extra prone to be wholesome, too. And, vice versa.

As extra older adults get again into the workforce,^[22] poor oral well being can considerably intrude with each the power to safe employment and keep it. 1 / 4 of Californians report that the looks of their mouth and enamel have an effect on their means to interview for a job.^[23] Nationally, employed adults lose greater than 164 million hours of labor yearly on account of dental illness or dental visits.^[24]

With such vital well being, social, and financial affect, the necessity to deal with limitations to oral well being care is important. This Information offers instruments for advocates to attach older adults to oral well being protection and care, and presents alternatives for advocates to interact in systemic advocacy.

Dental Insurance coverage Protection for Older Adults

Unique Medicare

This part describes oral well being protection for people who’ve Unique Medicare with out Medi-Cal protection. To evaluation how oral well being protection works for people enrolled in Medicare and Medi-Cal, generally known as Dually Eligible people, see Twin Eligible Medicare and Medicaid Enrollees.

Medicare Statute Excludes Routine Dental Care

Medicare is a federal medical insurance program that’s the main supply of protection for adults age 65 and over and for sure people with disabilities underneath age 65.^[25] Unique Medicare, sadly, doesn’t cowl most dental therapy. Underneath the regulation, dental companies “in reference to the care, therapy, filling, elimination, or substitute of enamel or buildings immediately supporting enamel” are particularly excluded from Medicare protection.^[26] Accordingly, routine dental care like preventive or restorative dental companies won’t be lined by Medicare, besides in very restricted circumstances as described under.

Exception: Medicare Covers Dental Care “Inextricably Linked” to Different Lined Companies

Underneath the Medicare statute, dental protection is allowable underneath a slim exception when dental companies are wanted to deal with an underlying medical situation.^[27] Beginning in 2022 and yearly thereafter, the Facilities for Medicare & Medicaid Companies (CMS) has launched steerage clarifying this exception and when it applies.^[28] For instance, the brand new steerage makes clear that Medicare pays for dental examinations and wanted dental companies to deal with Medicare-covered organ transplant, head and neck most cancers, most cancers previous to or throughout chemotherapy, cardiac valve substitute, or valvuloplasty process, and permits these companies to be rendered in an inpatient setting lined underneath Medicare Half A and an outpatient setting paid underneath Medicare Half B.^[29]

Most not too long ago, underneath the Doctor Payment Schedule remaining rule for 2025, CMS clarified that Medicare cost will be made for dental companies which can be inextricably linked to Medicare lined dialysis companies for the therapy of end-stage renal illness. Lined companies embody dental or oral examinations obtained on an in-patient or out-patient foundation, and medically vital diagnostic and therapy companies to eradicate an oral or dental an infection.^[30]

Whereas the exception stays slim, the clarifying steerage will assist Medicare enrollees with complicated well being care wants get hold of medically vital dental companies which can be “[…] inextricably linked and considerably associated and integral to the scientific success of different lined medical companies.”^[31]

Because the steerage of Medicare’s restricted protection of medically vital dental companies is new, CMS and suppliers within the medical and oral well being house proceed to work on implementation. Justice in Getting old will present ongoing schooling on this protection as we study extra. See additionally the dialogue under on oral well being protection for individuals dually eligible for Medicare and Medi-Cal.

Federal Advocacy to Develop Oral Well being Protection in Medicare

CMS Administrative Advocacy

Justice in Getting old is a part of a broad coalition of oral well being advocates and suppliers generally known as the Consortium for Medically Vital Oral Well being Care persevering with the work to additional make clear when Medicare will cowl dental therapy that’s “inextricably linked and considerably associated and integral to the scientific success of different lined medical companies.”^[33] The Consortium is advocating for CMS to contemplate the incorporation of further continual situations together with diabetes and varied autoimmune illnesses as eligible for Medicare protection of medically vital oral and dental therapy companies. For extra data, go to the Consortium for Medically Vital Oral Well being Protection.

Legislative Advocacy

There’s a nationwide marketing campaign underway so as to add dental companies to these advantages lined underneath Medicare Half B. Justice in Getting old in addition to quite a lot of different nationwide shopper organizations similar to Households USA, Heart for Medicare Advocacy, and AARP and oral well being organizations similar to CareQuest, have been engaged on this effort. For extra data, go to the Oral Well being part of Justice in Getting old’s web site. You too can be a part of the Oral Well being Progress and Fairness Community (“OPEN”) to get engaged.

Medicare Benefit

This part describes oral well being protection for people who’ve chosen a Medicare Benefit plan, and who don’t even have Medi-Cal protection. To learn how protection works for dually eligible people enrolled in Medicare and Medi-Cal, see Twin Eligible Medicare and Medicaid Enrollees.

Medicare Benefit (MA) plans, also called Medicare Half C, are managed care plans that contract with CMS to supply hospital, outpatient, and different well being care companies to Medicare enrollees who’ve determined to obtain their Medicare advantages by way of these well being plans moderately than via Unique Medicare.^[34] Many Medicare enrollees be a part of MA plans in an effort to cut back their out-of-pocket medical bills and to acquire advantages not lined by Unique Medicare, similar to dental care.[35]

MA plan members should use the plan for all their medical wants and comply with the plan’s guidelines, together with community supplier guidelines, besides in sure circumstances similar to emergency and pressing care conditions.^[36] Generally, if members use a supplier exterior the plan’s community, together with dental suppliers, with out plan authorization, they must pay the next co-payment or the complete price of the service. ^[37]

Most MA plans supply dental advantages – as of 2021, 94% of people enrolled in an MA plan had some type of dental protection.^[38] Nevertheless, the scope of dental care lined by these plans varies broadly from plan to plan. Most plans (86%) supply in depth protection, whereas some (14%) cowl solely routine examinations and cleanings. MA plans, like different types of dental protection, additionally usually impose limits on the frequency of a lined dental care (e.g. one cleansing per 12 months; or one set of dentures as soon as each 5 years).^[39]

Prices for dental protection additionally range. Whereas few plans general (10%) cost a premium for dental protection, most plans have vital price sharing, significantly for extra pricey dental companies. For instance, for restorative companies, most plans pay simply 50% of the lined service, leaving the member chargeable for the remaining 50%. It is usually frequent for plans to restrict the entire quantity they’ll pay for dental care in a given 12 months – known as the “most profit quantity.”^[40]

Medi-Cal Dental

Medi-Cal Fundamentals

The first supply of dental protection for low-income older adults in California is thru Medi-Cal. The Medi-Cal program is primarily administered by the Division of Well being Care Companies (DHCS), and the Division of Managed Well being Care (DMHC) additionally has oversight of Medi-Cal managed care well being plans. Most older adults (age 65 and over) and other people with disabilities (together with blindness) are eligible for Medi-Cal underneath the Aged, Blind, or Disabled Program if they’ve countable earnings at or lower than 138% of the Federal Poverty Stage ($1801/mo. for a person in 2025; $2,433 for a pair).^[42]

Older adults might also qualify for Medi-Cal via applications which have larger earnings limits, together with the 250% working disabled program and medically needy “share of price” Medi-Cal.^[43]

There are two main methods Medi-Cal delivers medical advantages: 1) Medi-Cal managed care plans and a couple of) fee-for-service.^[44] People enrolled in a Medi-Cal managed care plan should see suppliers contracted with the plan. The plan makes the choice as to what therapy it can authorize for an enrolled member. In the present day, practically all Medi-Cal recipients are enrolled in a managed care plan for his or her medical advantages. One exception are people who qualify for Medi-Cal via the medically needy pathway and have a share of price.^[45]

Medi-Cal Dental Overview

Any particular person who’s eligible for Medi-Cal can be eligible for dental advantages via Medi-Cal Dental (previously known as Denti-Cal).^[46] The historical past of the Medicaid dental profit in California has been uneven. Aside from Federally Required Grownup Companies (FRADS), grownup dental advantages are an non-obligatory profit underneath federal regulation.^[47] Accordingly, states shouldn’t have to supply dental advantages. When states do elect to cowl dental advantages, we regularly see them eradicated when states face a monetary downturn. California skilled this in 2009, at which period grownup dental advantages have been eradicated for adults residing in the neighborhood (advantages remained intact for people residing in expert nursing services or intermediate care services for the developmentally disabled).^[48] Fortunately, with a lot advocacy, advantages have been partially restored in Could 2014 and totally restored in January 2018.^[49]

Beneath is a abstract of the Medi-Cal Dental program together with how advantages are delivered, what advantages are lined, limitations in protection, how advantages are accessed, and Medi-Cal Dental appeals and grievances.

Medi-Cal Dental Supply System

The supply system for dental advantages underneath Medi-Cal is “carved out.” Because of this dental advantages are offered via a system that’s separate from the one that gives medical advantages. Dental advantages are delivered both via Payment-for-Service (FFS) or via a separate dental plan in Los Angeles and Sacramento counties. If a person is enrolled in a Medi-Cal managed care plan, that plan will not be chargeable for offering the dental profit.^[50]

Most people statewide obtain their dental advantages via Medi-Cal Dental fee-for-service. Because of this a person can go to any dental supplier who’s contracted with Medi-Cal Dental. As with Medi-Cal usually, the Division of Well being Care Companies (DHCS) oversees the Medi-Cal Dental program. Since October 2023, DHCS has contracted with Gainwell Applied sciences to hold out dental enterprise operations like processing claims, therapy authorizations, and supplier purposes (beforehand Delta Dental was chargeable for this function).^[51]

Medi-Cal enrollees in Los Angeles and Sacramento counties have the choice to hitch a separate Dental Managed Care (DMC) plan moderately than obtain their dental companies via fee-for-service.[52] Presently, the three DMCs obtainable in each counties are: Entry Dental Plan; Well being Web Dental; and Liberty Dental.^[53]

Medi-Cal Dental Lined Advantages

The Medi-Cal Dental program profit package deal is now pretty complete since advantages have been totally restored as of January 1, 2018.^[60]

Medi-Cal Dental now covers most preventive and restorative companies together with exams, cleanings, fluoride therapy, diagnostic testing (e.g. x-rays), fillings, crowns, root canals on each anterior and posterior enamel, gum therapy, and partial and full dentures.^[61] Medi-Cal Dental additionally covers all Federally Required Grownup Companies (FRADs). FRADs are dental companies that might be carried out by a medical physician (e.g., extractions).^[62] As a common rule, Medi-Cal Dental will solely pay for the bottom price process that may right the dental drawback.^[63]

There are additionally further limitations on dental advantages as described under.

The next is a fast reference information for lined advantages. The main points of all lined companies, together with all lined dental codes and their limitations, are spelled out of their entirety within the DHCS Medi-Cal Dental Supplier Handbook.

Fast Reference Information for Lined Advantages

*Beginning July 1, 2022, Medi-Cal Dental now covers laboratory-processed crowns on posterior enamel (i.e., molars) when medically vital to revive a tooth to regular perform.^[64]

Not lined for adults: Molar sealants and orthodontics (braces) are solely lined for kids and youngsters underneath the age of 21.^[65]

Teledentistry: DHCS permits suppliers the flexibleness to make use of teledentistry as a modality to render sure companies.^[66]

New Advantages (2023 and 2024): The Caries (tooth decay) Threat Evaluation (CRA) bundle and Silver Diamine Fluoride (SDF) are two new advantages added to the Medi-Cal Dental Program in alignment with nationwide dental care requirements.

Silver Diamine Fluoride is a comparatively new type of fluoride therapy that has been discovered efficient in slowing and stopping dental caries (tooth decay) in kids and adults, and particularly has proven efficacy in administration of root decay in older adults.^[67] Medi-Cal Dental will cowl these therapies in sure circumstances.^[68] For instance, Medi-Cal Dental will cowl SDF for adults as soon as each 6 months when a dental supplier submits required documentation demonstrating medical necessity and displaying, “[…] the underlying situations that exist which point out that nonrestorative caries therapy is perfect.”^[69]

As of December 1, 2024, Medi-Cal dental suppliers are allowed to invoice and obtain reimbursement by way of Medi-Cal Dental for lined oral well being schooling and oral well being navigation companies offered to members by eligible Neighborhood Well being Staff (CHWs).^[70]

Medi-Cal Dental Protection Limitations

Medically Vital

All dental companies have to be deemed medically vital in an effort to be reimbursed by Medi-Cal Dental. Medical necessity refers back to the standards used to resolve if lined companies are vital and acceptable for the therapy of the enamel, gums, and supporting buildings in line with professionally acknowledged requirements of apply.^[71]

Scope and Sort

Nearly all dental companies lined underneath Medi-Cal Dental are restricted in scope. For instance, you may solely obtain one cleansing (prophylaxis) per 12 months and protection for crowns or dentures each 5 years. There are slim exceptions to those limitations. For instance, a dentist can request prior authorization for extra frequent cleanings for a affected person with a bodily limitation and/or an oral situation that stops each day oral hygiene.^[72]

Additional, whereas dentures are solely a profit as soon as in a five-year interval, a person can get hold of a brand new denture sooner if they’ll adequately doc and meet 5 exceptions: 1. catastrophic lack of the prosthetic past the management of the person with required documentation together with and never restricted to an illustration of continued medical necessity; 2. want for a brand new prosthesis on account of surgical or traumatic lack of the oral-facial construction; 3. if the denture is now not serviceable as licensed by a dentist; 4. dentures now not match on account of vital medical situation requiring medical documentation from the dental supplier; or 5. for a non-catastrophic loss or misplacement, “Documentation should embody an evidence of preventive measures instituted to alleviate the necessity for additional substitute.”^[73]

Dental companies are additionally restricted in kind. For instance, Medi-Cal Dental won’t pay for a gold crown, however will reimburse for prefabricated steel and resin crowns, and sure types of porcelain crowns. Equally, Medi-Cal Dental will solely pay for lab processed crowns when a tooth has suffered particular types of harm.^[74]

Annual Mushy Cap

Medi-Cal Dental for adults 21 years of age or older has an annual mushy cap for advantages of $1800.^[75] The mushy cap doesn’t apply to medically vital companies and procedures similar to these rendered to residents of long-term care services, emergency companies with the required documentation, dentures, companies which can be federally mandated together with FRADS along with different companies.^[76] Aside from procedures deemed medically vital, dental suppliers have the accountability to confirm the mushy cap to make sure it has not been reached previous to rendering companies.

Accessing Medi-Cal Dental

Discovering a Supplier

To search out suppliers, enrollees in dental managed care plans in Sacramento and Los Angeles counties can contact their plans immediately or entry their plan’s supplier listing on-line. Enrollees in Medi-Cal Dental Payment-For-Service can go to the “Medi-Cal Supplier Listing” on-line for a listing of suppliers organized by county and metropolis. ^[77] Although Medi-Cal doesn’t assure that suppliers listed will probably be accepting new sufferers, the listing offers an possibility to incorporate suppliers which can be accepting new sufferers. Enrollees who want help discovering a dental supplier of their space can ask for care coordination help. Medi-Cal Dental is chargeable for offering care coordination companies and helping individuals with finding suppliers, accessing appointments, acquiring translation companies, and getting transportation.^[78] Medi-Cal Dental can even help members by offering referrals to Medi-Cal dentists that will not in any other case settle for new sufferers exterior of the DHCS referral course of.^[79] People or their representatives can name Medi-Cal Dental at 1-800-322-6384 or full the on-line care coordination type to request coordination help.

Prior Authorization

Aside from emergency companies, most Medi-Cal Dental companies require a dental supplier to acquire prior approval earlier than rendering companies, known as a therapy authorization request (TAR). You will need to notice {that a} Medical Screening by a Medical Screenings Dentist (CSD) is required for all TARs for members in state licensed services together with Intermediate Care Amenities (ICFs), and Expert Nursing Amenities (SNFs), aside from circumstances involving lower than 4 extractions, or lower than three restorations.^[87]In sure circumstances, x-rays should even be submitted with the TAR. In conditions when x-rays can’t be obtained due to the affected person’s medical situation, bodily means, or cognitive perform, images could also be taken as a substitute. Nevertheless, documentation explaining why x-rays weren’t taken have to be included within the TAR or declare.^[88] The Supplier Handbook units forth which procedures require prior authorization and what further documentation is required for companies to be rendered.^[89]

Discover of Authorization

If a supplier submits a therapy authorization, the supplier will obtain a discover of authorization both approving or denying the authorization. If the authorization is denied, the supplier will probably be knowledgeable of the explanation why and has the choice to submit a request to reevaluate the authorization.^[90] A listing of adjudication codes will be present in Part Seven of the Supplier Handbook.^[91]

Discover of Motion

The beneficiary must also obtain a discover of motion (NOA) from Medi-Cal Dental (or from the managed care plan in these counties) when an authorization for therapy is denied or modified. This discover ought to embody a cause for the denial and supply the beneficiary the chance to attraction the discover.^[92] Included on this Information in Appendix B are the Purpose for Motion Codes summarizing the the explanation why a declare has been denied. Appeals and grievances are mentioned in additional element under.

Advocates working with enrollees have reported situations the place suppliers both haven’t submitted a TAR in any respect or have submitted one incorrectly, then knowledgeable the affected person that the service has been denied and the person must pay out-of-pocket. To make sure enrollees obtain the advantages they’re eligible for, it is very important report any occasion wherein a discover has not been obtained.

Co-Funds

Suppliers can now not accumulate copayments from Medi-Cal Dental enrollees as Medi-Cal’s authority to gather cost ended on January 1, 2023.^[93]

Share of Value

Some Medi-Cal recipients who’re over the earnings restrict for Medi-Cal change into eligible with a share of price (SOC) also called a spend-down quantity. SOC eligibility capabilities very similar to a deductible: Medi-Cal (or on this case Medi-Cal Dental) won’t pay for companies till the person has incurred sufficient medical (together with dental) bills to fulfill their month-to-month SOC. The supplier is allowed to require the Medi-Cal Dental enrollee to pay their SOC on the day the companies are rendered.^[94]

Transportation

Medi-Cal recipients are entitled to transportation to medical appointments, which embody dental appointments, however securing transportation to dental therapy is completely different based mostly on the kind of transportation wanted.^[95]

Non-Emergency Medical Transportation

If a person wants transportation by way of medical mode of transportation – generally known as Non- Emergency Medical Transportation (NEMT) – the person ought to first attempt to contact their Medi-Cal plan to rearrange transportation. Medical transportation by way of NEMT consists of wheelchair or litter vans. Whereas Medi-Cal plans should not required to rearrange NEMT to carved out companies like dental, some Medi-Cal plans choose to take action. If the Medi-Cal plan won’t organize the NEMT transportation or if the person will not be enrolled in a Medi-Cal plan, the Medi-Cal Dental supplier is required to arrange NEMT transportation to the appointment. No matter Medi-Cal protection kind, in an effort to obtain NEMT transportation companies, all people will want a prescription from their supplier. The supplier will then have to submit documentation demonstrating medical necessity via prior authorization.^[96]

Medi-Cal dental suppliers are licensed to contact NEMT transportation corporations and submit all requests on to them. The transportation firm will then submit a TAR to the Medical Assurance and Administrative Assist Division (CAASD) inside DHCS, who will evaluation and approve the TAR if medical necessity is demonstrated.^[97]

Non-Medical Transportation

If the person can journey by normal conveyance (e.g. automotive, bus, and many others.) – generally known as non-medical transportation (NMT) – however has no technique of acquiring one of these transportation, the person’s Medi-Cal plan is required to supply NMT to dental companies. ^[98] To arrange a experience, enrollees ought to contact their plan immediately and ask about transportation suppliers authorized by the plan of their space. People not enrolled in a Medi-Cal plan ought to ship an e mail request to coordinate transportation companies with out confidential data to DHCSNMT@dhcs.ca.gov. They’ll additionally contact transportation suppliers on to schedule companies if they’ve their contact data. Not like NEMT, the dental supplier has no accountability to rearrange NMT. To keep away from protection points, people ought to make the most of solely Medi-Cal authorized transportation.^[99]

Day of Appointment

On the day of an appointment, people ought to carry their Medi-Cal card (a.okay.a. beneficiary identification card) with them. If the person is in a separate dental plan, they need to additionally carry their dental plan card. If a person wants interpreter companies, the dental supplier should present one freed from cost. The dental supplier additionally should adjust to the People with Disabilities Act and is prohibited from discriminating on the premise of race, colour, nationwide origin, intercourse (together with sexual orientation or gender id), age or incapacity.^[100]

If a person can not discover a dentist that speaks their language, they’ve the appropriate to an interpreter at no cost. People ought to contact the Medi-Cal Dental phone service heart at 1-800-322-6384 to request an interpreter.

Billing Prohibitions

Medi-Cal Dental suppliers are prohibited from billing Medi-Cal recipients for any Medi-Cal Dental lined service aside from for share of price (as described above).^[101] There are restricted circumstances when suppliers are allowed to enter into a personal contract and cost enrollees. For instance, suppliers can solely cost for non-covered companies if the person understands that it isn’t a lined profit and that they are going to be chargeable for cost.^[102] Medi-Cal Dental suppliers who violate these guidelines are topic to sanctions as much as 3 times the Medi-Cal reimbursement price.^[103] Medi-Cal Dental suppliers may also be reported to California Dental Board or sued underneath the state’s Client Authorized Cures Act and the Unfair Competitors Legislation for improper billing.^[104]

Upselling, and Dental Credit score Playing cards

Though most elementary advantages are actually lined underneath Medi-Cal Dental, suppliers could try to upsell uncovered companies that could be higher high quality, or new therapies not but lined by Medi-Cal Dental (e.g. Arestin, bone grafts). First, suppliers are prohibited from making a Medi-Cal Dental lined service contingent on receiving an uncovered service.^[105] And as said beforehand, suppliers can solely cost Medi-Cal Dental recipients for uncovered companies if the person is knowledgeable that the companies should not lined by Medi-Cal Dental and that the person will probably be chargeable for cost for these non-covered companies. Medi-Cal Dental suppliers are inspired to supply this data in writing.^[106]

Usually talking, as a result of Medi-Cal recipients shouldn’t have the earnings or assets to pay for uncovered companies, it’s advisable that they restrict the therapy they get hold of to these companies lined by Medi-Cal Dental.

Nevertheless, if a person, having been knowledgeable of the above, decides to proceed with the therapy, they are going to be chargeable for the associated fee. Many suppliers will supply sufferers the chance to finance the price of these uncovered companies via a dental or care bank card. Medi-Cal recipients ought to be very cautious about coming into into these credit score preparations.^[107] Advocates ought to encourage shoppers to not really feel rushed to enter into the settlement, to learn the phrases and situations fastidiously, and to first discover all different low- or no-cost choices mentioned under. Usually, these bank cards and related cost preparations expose the person to very excessive rates of interest that may result in a cycle of debt. People who don’t communicate English ought to request that the data be offered to them in a language they perceive earlier than signing any paperwork.

There are further particular protections for dental bank cards. As of July 1, 2020, suppliers and their workers are prohibited from arranging for or establishing an open-end credit score or mortgage that incorporates a deferred curiosity provision and from finishing any portion of an software for credit score or a mortgage for the affected person or establishing an software that’s not utterly crammed out and signed by the affected person.^[108] Suppliers and their workers are required to supply sufferers with a written discover of credit score, written therapy plan, an estimate of prices, and signed acknowledgment that the affected person’s rights and obligations have been offered within the acceptable threshold language. ^[109] If the supplier fails to adjust to these necessities, the person is entitled to aid pursuant to the Client Authorized Cures Act and Unfair Competitors Legislation.^[110]

In case your consumer has entered right into a dental or care credit score association, it’s advisable that they get hold of authorized illustration. The Well being Client Alliance has skilled authorized companies attorneys on this subject who’re outfitted to help with these kinds of circumstances. See Appendix A for contact data.

Medi-Cal Dental Appeals and Grievances

What’s the distinction between an attraction and grievance?

An attraction is a proper approach of asking Medi-Cal Dental or a Medi-Cal Dental plan to alter a call relating to protection. A grievance is any criticism aside from one for a protection determination (e.g., a supplier was impolite to the enrollee or offered poor high quality of care).

Appeals

Medi-Cal Dental Payment-for-Service

Many main dental companies require the supplier to submit a therapy authorization request (TAR) previous to rendering companies. In situations the place the TAR is denied, each the person and the supplier ought to obtain a discover informing them of the denial and the explanation for the denial (see Appendix B for denial codes and causes). Since most Medi-Cal Dental recipients are in fee-for-service, they’ve a proper to request a state truthful listening to as quickly as they obtain a discover of motion denying a service. The listening to have to be requested inside 90 days of the date of the discover.^[111]

Medi-Cal Dental Managed Care

People enrolled in a Medi-Cal dental managed care plan have a distinct appeals course of than fee-for-service. After receiving a denial discover, the person should first file an attraction with the dental plan. If the dental plan denies the attraction, the person can request a state truthful listening to or proceed with the plan appeals course of by requesting an inner medical evaluation (IMR) or do each. For instance, if a person asks for an IMR first, however doesn’t agree with the choice, they’ll nonetheless ask for a state listening to later. Nevertheless, if the person asks for a state listening to first, and the listening to has already taken place, the person can not ask for an IMR. On this case, the state listening to has the ultimate say.^[112]

Grievances

You will need to file a criticism or grievance with Medi-Cal Dental or the Medi-Cal Dental plan any time a person experiences an issue with the Medi-Cal Dental program. This ensures that the Medi-Cal Dental program is made conscious of points people face in this system and this system stays accountable to handle these points. Grievances ought to be filed in situations the place an attraction has been filed if the problem goes past simply a typical denial of protection, and in addition in situations the place a person has to attend lengthy intervals for an appointment, obtained poor care, was handled rudely, was not offered language help, or was improperly billed.

Medi-Cal Dental Payment-For-Service

A person can file a grievance by contacting the Medi-Cal Dental Phone Service Heart at 1-800-322-6384. The criticism will be taken over the cellphone. The person can even file a criticism by filling out a criticism type obtainable at and mailing it to Medi-Cal Dental. Medi-Cal Dental should acknowledge receipt of the grievance inside 5 (5) days of receiving the criticism and should make a conclusion inside 30 days. If the person will not be glad with the conclusion, they’ll request a state truthful listening to.^[113]

Medi-Cal Dental Managed Care

If the person is in a dental managed care plan, the grievance ought to be filed with the plan. You will need to ask the plan to formally take a grievance. Whereas some points will be resolved rapidly, it’s problematic when plans don’t formally settle for and reply to a grievance since there isn’t a report of the incident. We due to this fact suggest that advocates insist that plans report the grievance.^[114]

Integration and Medi-Cal Dental

As talked about beforehand, Medi-Cal Dental is a carved-out profit and isn’t built-in with the supply of medical care. Medical docs are unlikely to look at a person’s mouth, and likewise, dental suppliers don’t at all times contemplate the person’s medical situation in treating their oral well being points. For instance, older adults usually take a number of drugs, lots of which trigger dry mouth and exacerbate oral well being points. Equally, diabetes will increase the chance of infections forming within the mouth, so the necessity for normal gum therapy is essential. In a perfect built-in world, we might see medical suppliers connecting their sufferers with diabetes to oral well being suppliers. In recent times, there have been updates to the Medi-Cal dental program to assist with integration of dental care with medical care.

Medi-Cal Dental Case Administration

Dental Case Administration is a particular program supplied by Medi-Cal Dental to help Medi-Cal enrollees who’ve complicated well being care wants and face challenges scheduling and coordinating therapy plans involving a number of medical and dental suppliers. This program goals to help people with vital medical, bodily, or behavioral situations that require specialised care, together with individuals with bodily, developmental, psychological, sensory, behavioral, cognitive, or different impairments that require medical administration, hospital dentistry, well being care intervention, and/or use of specialised companies or applications.^[115]

To acquire Dental Case Administration, a person’s medical supplier, dental supplier, caseworker, or healthcare skilled should make a referral by finishing the Case Administration Referral Type. Referrals are evaluated by the Medi-Cal Dental Buyer Service Heart.

Medi-Cal Plan Duties

Meeting Invoice 2207 requires Medi-Cal plans to incorporate a dental screening within the well being danger evaluation they have to conduct for every enrollee.^[116] If Medi-Cal plans should not helping with connecting their members to dental companies, it will be significant for advocates to report this to the Division of Well being Care Companies.

Program of All-Inclusive Look after the Aged (PACE)

The Program of All-Inclusive Look after the Aged (PACE) offers complete medical and social companies to older adults who meet the next eligibility standards: people should dwell within the PACE service space; be 55 or over; meet a nursing facility degree of care; and have the ability to safely dwell in the neighborhood.^[117] PACE plans present all Medicare and Medi-Cal lined companies, together with lined dental companies, at a PACE web site. If the PACE web site is unable to carry out a lined dental service on the web site, the person will probably be referred to a neighborhood supplier.

Business Plans & Dental Financial savings Plans

Business Plans

Older adults who should not eligible for Medi-Cal, and who’ve the monetary means, could need to contemplate buying a industrial dental plan. There are frequent options with these plans that people ought to evaluate when purchasing for protection.^[118] These plans will embody prices for month-to-month premiums and an annual deductible that have to be met earlier than the plan pays for companies. Plans nearly at all times may even have a low annual profit most (e.g. starting from $1,000 – $2,000).^[119] One other frequent characteristic is a ready interval: people should be enrolled within the plan for six months, for instance, earlier than being eligible to obtain most lined companies. Most companies won’t be lined at 100%. As an alternative, the person will probably be chargeable for coinsurance or the plan will supply a reduction on main companies (e.g. 25% low cost on companies by in-network suppliers).

Advocacy from the California Dental Affiliation (CDA) and others in 2023 resulted in passage of a number of payments that provide promising alternatives to enhance industrial dental plans for shoppers and suppliers in California. For instance, Meeting Invoice 1048 and Meeting Invoice 952 are vital to uplift as each took impact January 2025. Meeting Invoice 1048 prohibits denials based mostly on pre-existing situations, prohibits plans within the massive group market from imposing ready intervals, and requires state regulatory evaluation of the premiums charged by dental plans to assist shield shoppers from unreasonable or unjustified charges.^[120] Meeting Invoice 952 works to supply extra transparency and eliminates confusion for shoppers by requiring dental plans to reveal via their on-line affected person portal or upon a dental workplace’s request whether or not the affected person’s plan is state regulated.^[121]

Dental Financial savings/Low cost Plans

Dental Financial savings/Low cost Plans should not actually plans in any respect within the conventional sense. Slightly, a person pays an annual charge after which receives reductions from suppliers who’ve agreed to simply accept the plan. The reductions range relying on the service sought. For instance, a person might obtain a 60% low cost on an annual examination and a 40% low cost on a crown. Not like a industrial plan, these financial savings plans usually shouldn’t have annual profit maximums or ready intervals. Once more, it will be significant for people to check plans for price, advantages, and entry to suppliers.^[122]

Particular Populations

Twin Eligible Medicare and Medicaid Enrollees

Dually eligible individuals – people who’ve each Medicare and Medi-Cal protection – usually expertise distinctive limitations to accessing care due to their twin standing. The first limitations duals face in accessing oral well being care happen after they choose to enroll in a Medicare Benefit (MA) plan that gives dental protection as a supplemental profit. They might encounter difficulties due to how the MA plan interacts with their Medi-Cal Dental protection. Twin eligible people ought to evaluation their MA plan dental protection fastidiously and perceive the dental protection offered by the plan. MA dental supplemental advantages are sometimes not complete. Beneath is a abstract of how protection ought to work.

Medicare Benefit or different Dental Protection + Medi-Cal Dental

For dually eligible individuals, Medicare protection pays main on Medicare lined companies, and Medicaid protection pays as a secondary medical insurance payor.^[123] Therefore, Medi-Cal is usually at all times the payor of final resort. Because of this for a dually eligible particular person enrolled in an MA plan that features dental protection, the MA plan ought to be main with few exceptions. Accordingly, dually eligible people ought to see dental suppliers which can be contracted with their MA plan for MA lined dental companies.

Since Medi-Cal Dental is secondary or payor of final resort, twin eligible enrollees in MA plans at occasions are improperly billed for companies which can be lined by Medi-Cal Dental. In these conditions, dually eligible people are nonetheless protected against billing so long as they’re handled by a Medi-Cal Dental supplier – even when the supplier will not be contracted with the MA plan. ^[124] This usually happens when an individual is mistakenly handled by a dental supplier they thought was of their MA plan’s community (however will not be within the MA community) or when they didn’t know their MA plan supplied dental advantages which can be additionally lined by Medi-Cal they usually went to their Medi-Cal Dental supplier for companies.

Medicare-Medicaid Plans

On January 1, 2023, Cal MediConnect plans transitioned to Medicare Medi-Cal plans (MMPs or Medi-Medi plans) offered by the identical corporations that offered Cal MediConnect plans.^[130] The transition occurred in all Coordinated Care Initiative (CCI) counties together with: Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Mateo, and Santa Clara counties. Medi-Medi plans are a particular kind of MA plan generally known as a Twin Eligible Particular Want Plan (D-SNP) and are chargeable for delivering all Medicare and Medi-Cal advantages underneath one plan (with exceptions, similar to carved-out dental advantages). In 2023, Medi-Medi plans have been supplied solely within the seven counties listed above. In 2024, Medi-Medi plans have been prolonged to 5 further counties together with Fresno, Kings, Madera, Sacramento, and Tulare. By 2026, these plans will probably be obtainable to twin eligible Californians in further counties.^[131]

Dental advantages proceed to be carved-out from Medi-Medi plans, which signifies that plan enrollees nonetheless obtain their dental care protection from Medi-Cal Dental.^[132] Some Medi-Medi Plans additionally supply supplemental dental advantages—these supplemental advantages wrap round what’s delivered by Medi-Cal Dental. DHCS requires that plans embody details about Medi-Cal Dental advantages in any supplies that present member details about the dental supplemental advantages.^[133] As completely aligned enrollment (EAE) plans,^[134] Medi-Medi plans are required to have aligned networks of suppliers, such that their contracted dental suppliers should even be enrolled in Medi-Cal Dental to assist retain continuity and reduce improper billing.^[135]

Nursing Facility Residents

Nursing facility residents have poorer oral well being than the overall inhabitants. That is true even though nursing facility residents retained full dental advantages underneath Medi-Cal after they have been eradicated for adults residing in the neighborhood in 2009.^[136] Whereas protection is complete, nursing facility residents face completely different limitations to entry. For instance, residents obtain their oral well being therapy primarily inside the partitions of the nursing facility since residents have a tougher time searching for therapy in the neighborhood. The result’s that almost all residents solely obtain therapy after they have an acute want and obtain fewer preventive companies. With a rising variety of Black and Hispanic/Latino residents in nursing facility care, and with documented disparities within the high quality of care offered by nursing dwelling services serving communities of colour,^[137] oral well being care stays an fairness difficulty that requires sustained advocacy. We hope with sturdy advocacy we will enhance oral well being care entry throughout all California nursing properties together with people who serve communities of colour. Listed here are particular methods to advocate for residents in nursing services.

Nursing Facility Residents Have Poorer Oral Well being^[138]

Entry to Companies

Nursing services are required to evaluate a resident’s dental and dietary standing upon admission, and thereafter quarterly, and when there’s a vital change within the resident’s situation.^[139] Nursing services are required to finish the Minimal Information Set (MDS) – a federally required scientific evaluation of all residents in Medicare and Medicaid licensed nursing properties. Two sections of the MDS establish oral well being wants. Part Ok consists of questions across the resident’s means to swallow and their dietary standing, and Part L particularly covers oral well being issues, together with damaged or loosely becoming dentures, no pure enamel, mouth ulcers or lesions, apparent cavities, damaged enamel or unfastened enamel, mouth ache, and infected or bleeding gums.^[140]

If oral well being wants are recognized in the course of the evaluation or anytime thereafter, the ability is required to help residents in acquiring each routine and 24-hour emergency dental care. Dental wants and the way they’re to be addressed have to be included within the care planning course of.^[141] In apply, this usually signifies that nursing services will organize for a dentist to go to a facility regularly, and residents who’re experiencing acute dental points will probably be signed as much as be seen. However services are required to do extra. Particularly, pursuant to federal regulation, services are immediately chargeable for the oral well being wants of their residents.^[142]

Pursuant to federal regulation, services are immediately chargeable for the oral well being wants of their residents.

The power is required to verify a dentist is accessible to residents via having a contract association with a dentist or using a workers dentist. If a resident is unable to pay for dental companies, the ability is meant to try to seek out different care or funding to make sure the resident has the very best practicable degree of well-being. The power can be supposed to make sure entry to routine care (e.g., gum therapy, cleanings) and should, if vital or requested, help the resident in making dental appointments and arranging transportation to and from these dental companies.^[143]

Nursing services should not permitted to cost for private hygiene objects, together with dental floss, denture cleaner, denture adhesive, denture cups, toothpaste, or toothbrushes for residents who’re paying for his or her keep via Medicare or Medi-Cal.^[144]

Oral Hygiene

Many residents in nursing services are unable to hold out the actions required to keep up their oral well being. For these residents, nursing services are required to supply companies similar to brushing of the enamel, cleansing dentures, and cleansing the mouth and tongue to keep up oral mucosa.^[145]

Misplaced Dentures

Nursing facility residents’ dentures usually go lacking. That is problematic when dentures are a lined profit solely each 5 years underneath Medi-Cal Dental. California services are required to ascertain and keep a written stock of a resident’s property, together with dentures.^[146] Amenities are additionally required to engrave a resident’s dentures to mark possession.^[147] Federal guidelines require services to have a coverage in place that identifies situations when the loss or harm of dentures is the ability’s accountability and prohibits the ability from charging the resident for the loss or harm when the ability is at fault. Amenities additionally should make a referral to a dental supplier inside three (3) enterprise days when dentures are misplaced or broken. ^[148]

Residential Care Amenities for the Aged

Residential Care Amenities for the Aged (RCFE), additionally known as “Assisted Dwelling” or “Board and Care” are non-medical services for older adults who require help with actions of each day residing. RCFEs are required to help in arranging for dental take care of residents and supply help with assembly dental wants, together with helping with offering or arranging transportation to dental companies.^[150]

Residents of Intermediate Care Amenities for the Developmentally Disabled

Intermediate Care Amenities for the Developmentally Disabled (ICF-DDs) present care and help companies to people with a developmental incapacity whose main want is for developmental companies and who’ve a recurring however intermittent want for expert nursing companies. California state regulation units forth further and particular necessities across the provision of dental care in ICF-DDs.^[151] For instance, ICF-DD workers have to be skilled on diet and methods to correctly conduct oral hygiene. The power additionally should keep a everlasting dental report for every resident and report dental progress and have in place a proper association for offering residents with dental companies.

Different Oral Well being Remedy Choices

Some older adults shouldn’t have entry to any dental protection or solely have restricted protection via Medicare or industrial plans. There are a selection of choices obtainable that, whereas not complete or at all times obtainable, are price exploring.

There are 2,641 Federally Certified Well being Clinics together with neighborhood well being facilities (CHCs) in California that present care to five,797,252 million Californians.^[152] CHCs are nonprofit, tax-exempt clinics which can be licensed as neighborhood or free clinics, as outlined underneath Part 1204 of the California Well being and Security Code, and supply complete companies to sufferers on a sliding charge scale foundation or, within the case of free clinics, at no cost to the sufferers. The time period “CHCs” consists of federally designated neighborhood well being facilities, migrant well being facilities, rural well being facilities, and frontier well being facilities. CHCs present quite a lot of neighborhood companies together with main medical care, pediatrics and prenatal care, behavioral well being care, and oral well being care. Many neighborhood well being facilities have full dental clinics that may present extra complete dental companies. A searchable record of neighborhood well being facilities is accessible at the California Division of Well being Care Entry and Data (HCAI) web site.

Neighborhood well being facilities settle for each Medi-Cal and Medicare in addition to most industrial insurance coverage choices. CHCs serve all sufferers no matter their means to pay, which makes them a beautiful possibility for older adults searching for dental care who shouldn’t have protection via Medicare. One barrier older adults could face when trying to get care is lengthy wait lists on account of excessive demand. Many CHCs have pressing care hours and walk-in appointment slots, so it’s advisable for a person to contact the neighborhood well being heart of their space to find out how and when the CHC can greatest serve them, and ensure what dental companies are offered.

Neighborhood well being facilities are Medi-Cal suppliers and invoice Medi-Cal for dental companies rendered. If a person has Medi-Cal Dental protection, however is unable to discover a Medi-Cal Dental supplier in the neighborhood, searching for care at a neighborhood well being heart could also be an possibility.

Veterans Affairs

The VA gives complete dental care advantages to sure qualifying Veterans.^[153] If the person doesn’t qualify for VA dental advantages, people enrolled within the VA well being plan can enroll in a VA dental well being plan for a decreased worth via the VA Dental Insurance coverage Program.^[154]

To search out out in the event that they qualify for any dental care, Veterans can do any of the next:

Dental Faculties

There are seven dental colleges in California.^[155] These colleges usually present therapy to populations in want. Companies are often offered on a sliding scale and lots of dental colleges will settle for Medi-Cal Dental insurance coverage. Not all dental colleges present therapy to all populations, so it is very important contact the college to find out whom the college serves and whether or not the therapy sought is a service the college gives. See Appendix A for a listing of colleges and speak to data.

Pop-Up Clinics

There are efforts to bridge gaps in entry to dental care by offering care at massive pop-up clinics. These clinics are usually staffed by volunteers and supply a spread of various companies at no cost. The pop-up clinics are often arrange in a public house. Since these occasions are often crowded with lengthy waits, it is usually vital to perform a little research earlier than touring to a pop-up clinic to make sure the companies the person wants are being supplied. Pop-up clinics will be situated via the clinic schedule of the America’s Dentists Care Basis.

Conclusion

Oral well being is important to general well being. Whereas California has taken a important step in making certain low-income older adults have pretty complete protection via Medi-Cal Dental, limitations to accessing these advantages and high quality therapy are vital. It’s our intention that this Information will assist advocates navigate the system and empower them to establish and deal with systemic limitations to oral healthcare.

Appendix A – Assets

Client Help Assets

Beneath is a listing of shopper help applications that may help with particular person consumer points. This isn’t meant to be a complete record.

The next is a listing of organizations engaged in systemic oral well being advocacy in California for adults.

Written Assets

State Businesses

Coalitions and Federal Assets

Dental Faculties

• Loma Linda College Faculty of Dentistry, Loma Linda
• College of California, Los Angeles Faculty of Dentistry, Los Angeles
• College of California, San Francisco Faculty of Dentistry, San Francisco
• College of the Pacific Arthur A. Dugoni Faculty of Dentistry, San Francisco
• The Herman Ostrow Faculty of Dentistry of USC, Los Angeles
• Western College of Well being Sciences School of Dental Medication, Pomona
• California Northstate College, School of Dental Medication

Appendix B – Medi-Cal Dental Purpose for Motion Codes

Purpose for Motion Codes

01 Your help code covers emergency companies solely.

02 Data submitted by your dentist about your present dental situation doesn’t meet our minimal necessities for approval of this service.

03 The request for dental therapy marked with an “R” was modified to the process marked with an “S.” This alteration was based mostly on the data submitted by your dentist regarding your present dental situation or on program pointers.

04 Our information present this service(s) or an identical service(s) was beforehand licensed, paid for, or accomplished. (For instance: In some circumstances, procedures are restricted to as soon as in 12 months or as soon as in 5 (5) years and can’t be licensed once more besides underneath particular circumstances, which have to be documented by your dentist.)

05 We’re unable to confirm your dentist’s enrollment to take part in this system on the date the request was submitted.

06 The service as requested by your dentist, IS NOT A BENEFIT OF THE PROGRAM. Please contact your dentist for a distinct therapy plan.

07 You didn’t seem for a scheduled screening examination or did not carry present denture(s) (full or partial). Please contact your dentist to resubmit a request for this process.

08 Your dentist didn’t submit sufficient data to permit us to course of this request. Please contact your dentist to resubmit a request with new data.

09 X-rays present that the tooth doesn’t meet the necessities for a crown. No less than 51% of the tooth have to be lacking and/or decayed. The tooth could also be restored with a filling.

10 X-rays present that the tooth/enamel could have an an infection; please contact your dentist as one other service could also be wanted first.

11 Primarily based on x-rays, your dentist’s charting and/or confirmed by data we obtained from our screening examination, you shouldn’t have ample gum illness to wish a deep scaling.

12 This service can’t be licensed as a result of it’s associated to a denied process in the identical therapy plan submitted by your dentist.

13 Primarily based on the data submitted by your dentist and/or obtained from a screening examination, your present dental situation is secure and the requested service will not be wanted presently.

14 Primarily based on x-rays and/or confirmed by data we obtained from a screening examination, it has been decided that the tooth/enamel has/have worn down naturally or you might have bruxism (enamel grinding). The requested service will not be a advantage of this system to revive enamel worn down naturally or by bruxism or that shouldn’t have decay or haven’t fractured.

15 X-rays present the tooth is just too damaged down and can’t be repaired. Your dentist could possibly present a distinct therapy.

16 Our information present that the tooth has been restored with an appropriate filling or stainless-steel crown.

17 X-rays present the service requested can’t be authorized as a result of gum illness has destroyed the bone across the tooth. Your dentist could possibly suggest a distinct therapy.

18 The minimal necessities for orthodontic therapy couldn’t be verified by the Handicapping Labial-Lingual Deviation Index or submitted examine fashions.

19 A partial denture could be a profit solely when there’s a full denture on the other arch.

20 Root canal therapy have to be satisfactorily accomplished earlier than a crown will be thought of.

21 Tooth will not be totally developed. Your dentist could possibly suggest a distinct therapy.

22 Remedy will not be vital as a result of neither x-rays nor documentation helps that there’s nerve harm.

23 A stayplate could be a profit solely to exchange a lacking everlasting entrance tooth.

24 X-rays present that further extractions are vital earlier than the therapy plan will be authorized; please contact your dentist.

25 Primarily based on data submitted by your dentist, your enamel are in such a poor situation that the requested partial denture will not be a profit underneath this program.

26 Primarily based on the data submitted by your dentist, your enamel are secure presently and shouldn’t be changed by a full denture.

27 Primarily based on the data submitted by your dentist, you don’t have any opposing full denture; due to this fact, you don’t qualify for a partial denture. Nevertheless, in case you are lacking entrance enamel, you qualify for a stayplate.

28 Primarily based on x-rays, your dentist’s charting, and/or confirmed by data we
obtained from our screening examination, your enamel and/or gums are in such poor situation that the requested therapy will not be a profit underneath this program. Your dentist could possibly suggest a distinct therapy.

29 Deep scaling and gum therapies should not a profit for kids, aside from circumstances the place drugs have brought about the overgrowth of gum tissue.

30 Mounted bridges are allowable when extreme epilepsy, paraplegia or uncontrollable spasticity prevents the usage of a detachable denture.

31 Tooth will not be in its regular place and can’t be repaired underneath this program.

32 Primarily based on data obtained from a screening examination, your present denture is passable at this time.

33 Primarily based on data obtained from a screening examination, it has been decided that you simply can not adapt to a denture due to bodily limitations or well being situations.

34 The requested service will not be vital as a result of there are sufficient enamel remaining on this arch to help the opposing denture.

35 Throughout your screening examination, you indicated you don’t want extractions or another dental companies presently.

36 The variety of licensed visits has been adjusted as a result of you’ll flip 21 years of age earlier than therapy is accomplished. Please make preparations together with your dentist.

37 The tooth will not be seen on the submitted x-rays.

38 Primarily based on x-rays and/or confirmed by data we obtained from our screening examination, you want further therapy out of your dentist earlier than the process will be thought of.

39 X-rays present there’s not sufficient house current for the requested false tooth.

40 This program doesn’t cowl orthodontics when there are nonetheless child enamel current.

41 Primarily based on x-rays and/or confirmed by data we obtained from our screening examination, we’ve got decided that you’ve got bruxism (enamel grinding). The therapy of bruxism will not be a advantage of this program.

42 The process will not be a profit for a child tooth or for a child tooth able to fall out. Your dentist could possibly suggest a distinct therapy in your situation.

43 The process requested won’t right your dental drawback. Your dentist could possibly suggest a distinct therapy in your situation.

44 Primarily based on data obtained out of your dentist, it’s decided that the requested service is for beauty causes solely. Companies for beauty functions solely should not a advantage of this system.

45 Your present denture will be made passable by a laboratory reline.

46 We’re unable to confirm your eligibility on this program.

47 Your dentist should contact California Kids’s Companies previous to submitting this process for cost or authorization.

48 EPSDT-Supplemental Companies should not a profit for sufferers 21 years and older.

49 The EPSDT-Supplemental Service(s) requested will not be medically vital.

Endnotes

1. U.S. Division of Well being and Human Companies, Nationwide Institutes of Well being, “Oral Well being in America: Advances and Challenges,” § 3B at 1, (2021), (Accessed February 6, 2025). ↑
2. California Division of Public Well being, “Standing of Oral Well being in California: Oral Illness Burden and Prevention 2017,” (April 2017). ↑
3. Heart for Oral Well being, “A Wholesome Smile By no means Will get Outdated: A California Report on the Oral Well being of Older Adults,” (March 2018), at 8. ↑
4. Id. ↑
5. Nationwide Council on Incapacity, “Uncared for for Too Lengthy: Dental Look after Individuals with Mental and Developmental Disabilities,” (Fall 2017). ↑
6. Nationwide Institutes of Well being, supra notice 1 at 3B-32; Nationwide Institute of Dental and Craniofacial Analysis, “Tooth Loss in Seniors,” (Accessed August 3, 2024). ↑
7. Nationwide Institutes of Well being, supra notice 1 at 3B-2; See additionally Nationwide Institute of Dental and Craniofacial Analysis, “Dental Caries (Tooth Decay) in Seniors (Aged 65 and older),” (final visited August 3, 2024). ↑
8. Chamut, Steffany, et al. “Oral Well being Amongst Medicare Beneficiaries in Nursing Houses.” JAMA Community Open, 6(9), Sept. 2023 (final visited August 3, 2024). ↑
9. See California Division of Public Well being, “California Oral Well being Plan 2018-2028,” (January 2018). ↑
10. CA Division of Public Well being, Workplace of Oral Well being. “California Oral Well being Surveillance Plan 2019-2023,” 4 (Sept. 2019). ↑
11. Journal of Diet, “Meals Insecurity Is Related to Persistent Illness amongst Low-Revenue NHANES Contributors,” (February 2010). ↑
12. Well being and Human Companies, “Oral Well being in America: A Report of the Surgeon Normal,” (2000). ↑
13. NIH, supra notice 1, at 3B-3. ↑
14. Jennifer M. Pusins et al., “Oral Well being and Aspiration Pneumonia,” In the present day’s Geriatric Medication, Vol. 11, No.6, (2018), p. 16.; See additionally F. Müller, “Oral Hygiene Reduces the Mortality from Aspiration Pneumonia in Frail Elders,” 94(3 Suppl.) Journal of Dental Analysis. 14S (Mar. 2015); Mikaela Brock et al., “The Relationships Amongst Periodontitis, Pneumonia and COVID-19,” Fig. 1, Frontiers in Oral Well being (Jan. 21, 2022). ↑
15. HHS, supra notice 12 at 283. ↑
16. See Nationwide Institutes of Well being, “Giant Research Hyperlinks Gum Illness with Dementia,” (July 9, 2020); M. Beydoun et al., “Medical and Bacterial Markers of Periodontitis and Their Affiliation with Incident All-Trigger and Alzheimer’s Illness Dementia in a Giant Nationwide Survey,” 75(1) J. Alzheimer’s Illness 157 (2020); Keshava Abbayya et al., “Affiliation between Periodontitis and Alzheimer’s Illness,” 7(6) N. Am. J. Med. Sci. 241 (Jun 2015). ↑
17. NIH,supranotice 1, at 3B-14. ↑
18. NIH,supra notice 1 at 2A-20; 3B-19; 5-2. ↑
19. Bryan Nack et al., “Opioid Use Dysfunction in Dental Sufferers: The Newest on Find out how to Determine, Deal with, Refer and Apply Legal guidelines and Rules in Your Apply,” 64(3) Anesthesia Progress 178 (2017). ↑
20. HHS, supra notice 12. ↑
21. American Journal Public Well being, “Burden of Oral Illness Amongst Older Adults and Implications for Public Well being Priorities,” (March 2012). ↑
22. Linda Childers, “Why Extra Retirees Are Going Again to Work,” AARP (September 29, 2023). ↑
23. American Dental Affiliation, Well being Coverage Institute, “Oral Well being and Nicely-Being in California,” (2015). ↑
24. HHS, supra notice 12 at 3. ↑
25. See Facilities for Medicare and Medicaid Companies, “Unique Medicare (Half A and B) Eligibility and Enrollment,” (Accessed February 7, 2025). ↑
26. 42 U.S.C. § 1395y(a)(12). ↑
27. Id. ↑
28. 42 C.F.R. § 411.15(i)(3). ↑
29. CMS, “HHS Finalizes Doctor Cost Rule Strengthening Entry to Behavioral Well being Companies and Entire-Individual Care,” (Nov. 1, 2022) (Accessed February 7, 2025). ↑
30. CMS, “Truth Sheets: Calendar 12 months (CY) 2025 Medicare Doctor Payment Schedule Last Rule,” (Nov. 1, 2024) (Accessed January 18, 2025). ↑
31. 42 C.F.R. § 411.15(i)(3)(i). ↑
32. Id. ↑
33. 42 C.F.R. § 411.15(i)(3)(i). ↑
34. CMS, “Well being Plans-Normal Data,” (Accessed February 7, 2025). ↑
35. Meredith Freed et al., Kaiser Household Basis, “Medicare and Dental Protection: A Nearer Look,” (July 28, 2021) [hereinafter “a closer look”]. ↑
36. See CMS, “Medicare Managed Care Handbook Chapter 4 – Advantages and Beneficiary Protections,” Part 20, Rev. 121, Issued: 04-22-16, p.29. (Accessed February 7, 2025). ↑
37. Id. at 6. ↑
38. Freed, supra notice 35. ↑
39. Id. ↑
40. Id. ↑
41. Medicare Rights Heart, “Inquiries to Ask Earlier than Becoming a member of Medicare Benefit,” (2025) (Accessed February 7, 2025). ↑
42. See DHCS, “2025 Federal Poverty Ranges,” Letter No.:25-01, (January 21, 2025), (Accessed February 7, 2025). ↑
43. For extra on Medi-Cal eligibility pathways, see Western Heart on Legislation & Poverty, “Getting and Maintaining Well being Protection for Low-Revenue Californians: A Information for Advocates,” (March 2016); . ↑
44. See DHCS, “Medi-Cal Dental Managed Care,” (Accessed August 04, 2024). ↑
45. Cal. Welf. and Inst. Code § 14184.200; Tiffany Huyenh-Cho, “Advocates Information: CalAIM for Older Adults and Individuals with Disabilities,” Justice in Getting old (March 2023) p. 8. ↑
46. See DHCS, “Medi-Cal Dental Supplier Handbook,” § 4 at 5 (2024), (Accessed February 7, 2025). ↑
47. Medicaid, “Obligatory & Elective Medicaid Advantages,” (Accessed August 4, 2024). ↑
48. Federally Certified Well being Facilities (FQHCs) sued to pressure California to proceed to fund their dental companies underneath Medicaid. The Ninth Circuit held that, underneath the federal Medicare and Medicaid statutes, the state was obligated to proceed to fund FQHC dental companies via its Medicaid program, regardless of that it had terminated Medicaid state plan dental advantages. See California Affiliation of Rural Well being Clinics v. Douglas, 738 F.3d 1007, 1016-17 (ninth Cir. 2013). ↑
49. WIC § 14131.10(b)(2)(C); DHCS Medi-Cal Dental, “Supplier Bulletin,” Vol 33, No 14 (Nov. 2017), (Accessed February 7, 2025). ↑
50. DHCS, supra notice 44; Welf. & Inst. Code 14087.46(a), Welf. & Inst. Code 14089.09(a) ↑
51. DHCS, “DHCS Stakeholder Updates: July 1, 2022,” (Final mod. Oct. 10, 2022). ↑
52. DHCS, “Medi-Cal Dental Member Handbook,” p. 2 (2023) ↑
53. DHCS, “Managed Care Plan Listing,” (Accessed July 09, 2024). ↑
54. DHCS, Medi-Cal Dental, “Supplier Bulletin,” Vol. 37, No. 21, (October 2021) (Accessed February 7, 2025). ↑
55. DHCS, “Medi-Cal Dental Managed Care (DMC) Methodology Overview,” p.3 (Could 31,2024) (Accessed July 10, 2024). ↑
56. See DHCS, “Dental Information Reviews,” (Accessed February 8, 2025). ↑
57. See DHCS, “Supplier Bulletin,” Vol. 39, No. 25 (Nov. 2023); DHCS, “Member Bulletin,” Vol. 6, No. 12 (Oct. 2023). ↑
58. See DHCS, “Managed Care Monitoring,” (Accessed February 8, 2025); CA Division of Managed Well being Care, “About Us,”(Accessed February 8, 2025). ↑
59. See DHCS, “Medi-Cal Managed Care and Psychological Well being Workplace of the Ombudsman,” (Accessed February 8, 2025). ↑
60. See DHCS, “What are the Medi-Cal Advantages?” (Accessed February 8, 2025). ↑
61. See DHCS, “Medi-Cal Dental,” (Accessed February 8, 2025); DHCS, supra notice 46, § 5 at 1. ↑
62. DHCS, supra notice 46, § 10 at 10-1. ↑
63. Id., § 2 at 21. ↑
64. DHCS, “Supplier Bulletin,” Vol. 38, No. 35, November 2022. ↑
65. DHCS, supra notice 53, at 9. ↑
66. DHCS, supra notice 46, § 4 at 4-22. ↑
67. American Dental Affiliation, “Silver Diamine Fluoride,” (Accessed February 8, 2025). ↑
68. DHCS, supra notice 46, § 4 at 16-17. ↑
69. Id. at 17. ↑
70. DHCS, “Supplier Bulletin,” Vol. 40, Quantity 37 (October 2024) (Accessed November 11, 2024). ↑
71. DHCS, supra notice 53, at 14. ↑
72. DHCS, supra notice 46, § 5 at 26. ↑
73. DHCS, “Supplier Bulletin,” Vol. 40, No. 13, (March 2024); See additionally supra notice 46, § 5 at 83; supra notice 46, § 6 at 49-50. ↑
74. Id., DHCS, supra notice 46, § 5 at 40-43. ↑
75. DHCS, supra notice 46, § 4 at 19. ↑
76. Cal. Welf. & Inst. Code § 14080(a); DHCS, supra notice 46, § 10 at 13. ↑
77. DHCS, “Medi-Cal Dental: Medi-Cal Supplier Listing,” (Accessed July 17, 2024). ↑
78. DHCS, “Member Bulletin,” Vol. 7, No. 5, (March 2024). ↑
79. See the DHCS Medi-Cal Dental supplier referral coverage at DHCS, “Supplier Bulletin,” Vol. 40, Num. 39, November 2024, (Accessed February 4, 2025). ↑
80. DHCS, Medi-Cal Dental Companies Division, “2021 Statewide Supplier and Member Surveys,” (Accessed July 18,2024). ↑
81. DHCS, “Medi-Cal Dental Companies Price Assessment,” p. 5 (October 2019), (Accessed July 18, 2024); DHCS, “Supplier Bulletin” Vol. 37, Num. 28, (December 2021) (Accessed July 19, 2024). ↑
82. DHCS, “Supplier Bulletin” Vol. 40, Num. 28, (July 2024) (Accessed July 18, 2024). ↑
83. DHCS “Proposition 56 Supplemental Dental Funds,” (Accessed July 20, 2024); DHCS, “Present Dental Terminology (CDT) Codes and Schedule of Most Allowances (SMAs) for Proposition 56 Supplemental Funds,” (Accessed July 20, 2024). ↑
84. California Dental Affiliation, “CDA Main Points & Priorities,” (April 2023). ↑
85. DHCS, and Dental Administrative Service Group, “2023 Medi-Cal Dental Member and Supplier Outreach Plan,” pp.2 and 17 (2023) (Accessed July 19, 2024). ↑
86. DHCS, supra notice 80. ↑
87. DHCS, “Medical Screening Dentist Handbook,” v. 1.1, pp. 8 and 25, (August 22, 2024). Notice the guide was made obtainable to advocates by way of a Public Data Act request. ↑
88. DHCS, “Skilled/Paraprofessional Adjudication Handbook,” v. 1.1, p. 64 (August 22, 2024). Notice the guide was made obtainable to advocates by way of a Public Data Act request. ↑
89. DHCS, supra notice 46 § 2 at 15, and § 5. ↑
90. DHCS,supra notice 46, § 6 at 19-20. ↑
91. DHCS, supra notice 46, § 7. ↑
92. DHCS, supra notice 53, at 23. ↑
93. DHCS Medi-Cal “Supplier Bulletin,” Vol. 40, Num. 19, (Could 2024), (Accessed July 24,2024). ↑
94. DHCS, supra notice 46, § 4 at 4-7. ↑
95. DHCS, “Transportation Companies,” (Accessed Aug. 3, 2022). ↑
96. DHCS,supra notice 46, § 9 at 24. ↑
97. Id. ↑
98. DHCS, “All Plan Letter 22-008 Non-Emergency Medical and Non-Medical Transportation Companies and Associated Journey Bills,” (Could 18, 2022), (Accessed February 8, 2025). ↑
99. DHCS, supra notice 95. ↑
100. See People with Disabilities Act of 1990, 42 U.S.C. § 12182(a); Part 1557 of the Inexpensive Care Act, 42 U.S.C. § 18116(a). ↑
101. DHCS, supra notice 46, § 2 at 17. ↑
102. DHCS, supra notice 102. ↑
103. WIC § 14019.4(c). ↑
104. California Civil Code § 1780(c); California Enterprise and Professions Code §§ 17200 et seq. ↑
105. DHCS, supra notice 102. ↑
106. DHCS, supra notice 46, § 2 at 19. ↑
107. Client Monetary Safety Bureau, “Medical Credit score Playing cards and Financing Plans,” (Could 2023) (Accessed February 8, 2025); For extra data, see Nationwide Client Legislation Heart, “Coping with Medical Debt: Client Recommendation from NCLC,” (2018), (Accessed February 8, 2025). ↑
108. California, State Legislature, S.B. 639 § 654.3(b)(e), Oct. 12, 2019. ↑
109. Enterprise & Professions Code § 654.3 (i)(j)(1); See additionally CA Meeting Invoice 171; DHCS Medi-Cal “Supplier Bulletin” Vol. 39, Num. 16, (July 2023), (Accessed July 26, 2024). ↑
110. Enterprise & Professions Code § 654.3(okay); California Civil Code § 1780. ↑
111. DHCS, supra notice 53, at 32. ↑
112. DHCS, “Grievance and Attraction Necessities, Discover and “Your Rights” Templates,” (Aug. 31,2022), (Accessed July 26, 2024); 42 CFR 438.402(c)(2)(ii). ↑
113. DHCS, supra notice 53, at 28-32. ↑
114. DHCS, supra notice 112, at 2. ↑
115. See DHCS, “Dental Case Administration Program,” (Accessed February 8, 2025). ↑
116. California, State Legislature, Meeting Invoice No. 2207, p.2., Feb. 18, 2016; see additionally WIC §14149.8(g). ↑
117. DHCS, “Program for All Inclusive Look after the Aged,” (Accessed Feb. 8, 2025). ↑
118. See Kimberly Lankford, “5 Issues You Ought to Know About Dental Protection and Medicare,” AARP, (Apr. 19, 2023). ↑
119. Freed,supra notice 35. ↑
120. California, State Legislature, Meeting Invoice No. 1048, (Oct. 8, 2025); See California Dental Affiliation (CDA), “Governor indicators second CDA-sponsored dental plan reform invoice in 2023,” Oct. 9, 2023, (Accessed July 27, 2024). ↑
121. California, State Legislature, Meeting Invoice No. 952, (July 27, 2023); California Dental Affiliation (CDA), “CDA-sponsored invoice signed into regulation, improves dental plan disclosures for dentists, sufferers,” Aug. 3, 2023, (Accessed July 27, 2024). ↑
122. See GoodRx Well being, “What Is a Dental Financial savings Plan?” April 3, 2023, (Accessed 07/29/2024). ↑
123. CMS, “A Fast Information to Medicare and Medicaid,” March 2024, (Accessed July 29, 2024). ↑
124. CMS, “Supplier Enrollment and Third Occasion Legal responsibility for Gadgets an Companies Rendered to Dually Eligible People,” January 14, 2025, at 2, (Accessed February 6, 2025). ↑
125. WIC § 14019.4; 42 U.S.C. § 1396a(n)(3)(B). ↑
126. DHCS, “Dental Advantages for Sufferers Dually Eligible for Medicare and Medi-Cal: Data for Dental Suppliers,” p. 2-3, January 2024, (Accessed July 29, 2024). ↑
127. Id. at 2–4. ↑
128. 42 C.F.R. § 422.504(g)(1)(iii); CMS, supra notice 36, at § 10.5.2. ↑
129. DHCS, supra notice 46, § 4 at 7. ↑
130. DHCS, “Data for Beneficiaries: Medi-Medi Plans,” (Accessed April 13, 2023). ↑
131. See DHCS, “California Advancing and Innovating Medi-Cal (CalAIM) Medicare Medi-Cal Plans (MMPs or Medi-Medi Plans),” (Accessed June 15, 2023); DHCS, “Medicare Medi-Cal Plans (Medi-Medi Plans),” (Accessed July 30, 2024); DHCS, “Medicare Medi-Cal Plan Listing,” (Accessed July 30, 2024). ↑
132. DHCS, “Medicare Medi-Cal Plans (Medi-Medi Plans),” at 2 (Accessed July 30, 2024). ↑
133. DHCS, “Exhibit A: Scope of Work Solely Aligned Enrollment D-SNP” 2025 SMAC, p.25, (Accessed July 31, 2024). ↑
134. DHCS, “CalAim Twin Eligible Particular Wants Plans Coverage Information Contract 12 months 2025,” p. 3, June 2024, (Accessed July 31, 2024). ↑
135. DHCS, supra notice 135, at 7. ↑
136. Heart for Oral Well being, supra notice 3. ↑
137. Ttyana P. Shippee, et al. “Addressing Racial and Ethnic Disparities in Nursing Houses,” AARP Public Coverage Institute, p. 4., February 1, 2024, (Accessed August 2, 2024). ↑
138. Id. ↑
139. 42 CFR § 483.20(b)(1)(xi). ↑
140. CMS, “Lengthy-Time period Care Facility Resident Evaluation Instrument 3.0 Consumer’s Handbook,” v. 1.15, p. 14, October 2017, (Accessed July 31, 2024). ↑
141. 42 CFR § 483.55(a)(1) (for expert nursing services); 42 CFR § 483.55(b)(1) (for nursing services). ↑
142. Surveyor’s Guideline to 42 CFR part 483.25, Appendix PP to CMS State Operations Handbook. ↑
143. 42 CFR § 483.55(a)(4). ↑
144. 42 CFR § 483.10(f)(11)(i)(E). ↑
145. 42 CFR § 483.24(a)(2); and Surveyor’s Guideline to 483.24(a)(2), F677, Appendix PP to CMS State Operations Handbook. ↑
146. HSC § 1289.4(d). ↑
147. HSC § 1289.4(h). ↑
148. 42 CFR § 483.55(a)(3)(5). ↑
149. DHCS, “Supplier Bulletin,” Vol. 40, No. 13, (March 2024), (Accessed July 31, 2024). ↑
150. 22 CCR § 87465. ↑
151. 22 CCR § 76359. ↑
152. See the Nationwide Affiliation of Neighborhood Well being Facilities, “California Well being Heart Truth Sheet,” (February 2025) (Accessed February 26, 2025). ↑
153. See the U.S. Division of Veterans Affairs, “VA Dental Care,” (Accessed August 01, 2024). ↑
154. U.S. Division of Veterans Affairs, “VA Dental Insurance coverage Program (VADIP): Truth Sheet,” (Sept. 2017); See additionally the U.S. Division of Veterans Affairs, “VA Dental Insurance coverage Program (VADIP),” (Accessed August 1, 2024). ↑
155. For extra details about the Dental Faculties of California, see Dental Board of California “Listing of California authorized dental colleges,” (Accessed August 1, 2024). ↑

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