Bill Text: CA SB980 | 2023-2024 | Regular Session | Amended
Bill Title: The Smile Act.
Spectrum: Slight Partisan Bill (Democrat 26-9)
Status: (Engrossed) 2024-08-15 - August 15 hearing: Held in committee and under submission. [SB980 Detail]
Download: California-2023-SB980-Amended.html
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Amended
IN
Assembly
June 10, 2024 |
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Amended
IN
Senate
May 16, 2024 |
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Amended
IN
Senate
March 21, 2024 |
CALIFORNIA LEGISLATURE—
2023–2024 REGULAR SESSION
Senate Bill
No. 980
| Introduced by Senator Wahab (Coauthors: Senators Allen, Alvarado-Gil, Archuleta, Atkins, Becker, Blakespear, Bradford, Caballero, Cortese, Dahle, Dodd, Grove, Hurtado, Laird, Limón, Newman, Ochoa Bogh, Padilla, Roth, Rubio, Stern, Umberg, Wiener, and Wilk) (Coauthors: Assembly Members Bryan, Chen, Davies, Lackey, Mathis, Ortega, Luz Rivas, Schiavo, Ting, and Waldron) |
January 29, 2024 |
An act to amend Section 14132.88 of the Welfare and Institutions Code, relating to Medi-Cal.
LEGISLATIVE COUNSEL'S DIGEST
SB 980, as amended, Wahab.
Medi-Cal: dental crowns and implants. The Smile Act.
Existing law establishes the Medi-Cal program, which is administered by the State Department of Health Care Services and under which qualified low-income individuals receive health care services, including certain dental services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Under existing law, early and periodic screening, diagnostic, and treatment (EPSDT) services are covered under Medi-Cal for an individual under 21 years of age in accordance with certain federal provisions.
Under existing law, for persons 21 years of age or older, laboratory-processed crowns on posterior teeth are a covered benefit when medically necessary to restore a posterior tooth back to normal function based on the criteria specified in the Medi-Cal Dental Manual of Criteria.
This bill, The Smile Act, for purposes of the above-described Medi-Cal coverage for laboratory-processed crowns, would remove the condition that the tooth be posterior and would apply the coverage to persons 13 years of age or older.
The bill would also add, as a covered Medi-Cal benefit for persons of any age, subject to prior authorization, a dental implant if tooth extraction or removal is medically necessary or if the corresponding tooth is missing. The bill would condition this coverage on there being no other covered functional alternatives for prosthetic replacement to correct the person’s dental condition, as specified, on the person being without medical conditions for which dental implant surgery would be contraindicated, on receipt of any necessary federal approvals, and on the availability of federal financial
participation.
Under the bill, the above-described provisions would not be construed to exclude Medi-Cal coverage for laboratory-processed crowns on teeth or dental implants if otherwise required under EPSDT services.
Digest Key
Vote: MAJORITY Appropriation: NO Fiscal Committee: YES Local Program: NOBill Text
The people of the State of California do enact as follows:
SECTION 1.
This act shall be known, and may be cited, as The Smile Act.SECTION 1.SEC. 2.
Section 14132.88 of the Welfare and Institutions Code is amended to read:14132.88.
(a) Notwithstanding subdivision (h) of Section 14132 and to the extent funds are made available in the annual Budget Act for this purpose, the following are covered benefits for beneficiaries 21 years of age or older under this chapter:(1) One dental prophylaxis cleaning per year.
(2) One initial dental examination by a dentist.
(b) The following are covered benefits for beneficiaries under 21 years of age under this chapter:
(1) Two dental prophylaxis cleanings per year.
(2) Two periodic dental examinations per year.
(c) (1) For persons 13 years of age or older, laboratory-processed crowns on teeth are a covered benefit when if medically necessary to restore the tooth back to normal function based on the criteria specified in the Medi-Cal Dental Manual of Criteria.
(2) Paragraph (1) shall not be construed to exclude Medi-Cal coverage for laboratory-processed crowns on teeth if otherwise required under early and periodic screening, diagnostic, and treatment (EPSDT) services pursuant to federal or state law.
(d) Any prefabricated crown made from ADA-approved materials may be used on posterior teeth and may be reimbursed as a stainless steel crown.
(e) (1) Subject to paragraphs (3) and (4), for qualified persons of any age, a dental implant is a covered benefit under this chapter if extraction or removal of the corresponding tooth is medically necessary.
(2) Subject to paragraphs (3) and (4), for qualified persons of any age, a dental implant is a covered benefit under this chapter if the corresponding tooth is missing.
(3) A dental implant is covered pursuant to paragraph (1) or (2) if no other covered functional alternatives for prosthetic replacement would correct the person’s dental condition,
as determined by the provider in consultation with an oral surgeon or periodontist.
(4) A dental implant is covered pursuant to paragraph (1) or (2) subject to prior authorization.
(5) This subdivision shall not be construed to exclude Medi-Cal coverage for dental implants if otherwise required under early and periodic screening, diagnostic, and treatment (EPSDT) services pursuant to federal or state law.
(6) For purposes of this subdivision, “qualified” means a person without medical conditions for which dental implant surgery would be contraindicated.
(f) Covered dental benefits and accompanying criteria for receipt of those dental benefits under
the Medi-Cal program shall be identified in the Medi-Cal Dental Manual of Criteria. Notwithstanding subdivision (h) of Section 14132, the department shall evaluate all covered dental benefits, including those listed in this section and in the Medi-Cal Dental Manual of Criteria, for evidence-based practices consistent with the American Academy of Pediatric Dentistry and the American Dental Association guidelines.
(g) (1) Except as provided in paragraph (2), the department shall require pretreatment radiograph documentation on posttreatment claims to establish the medical necessity for dental restorations. The pretreatment documentation required under this subdivision is intended to reduce fraudulent claims for unnecessary dental fillings. In order to avoid any undue barriers to accessing dental care, the
department shall stipulate that the pretreatment radiograph documentation for posttreatment claims will be required only when if there are four or more dental fillings being completed in any 12-month period.
(2) For any beneficiary who is under four years of age, or who, regardless of age, has a developmental disability, as defined in subdivision (a) of Section 4512, radiographs or photographs that indicate decay on any tooth surface shall be considered sufficient documentation to establish the medical necessity for treatment provided.
(3) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of
Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section, in whole or in part, by means of provider bulletins, plan letters, or other similar instructions, without taking regulatory action.
(h) This section shall be implemented only to the extent that any necessary federal approvals are obtained and federal financial participation is available.
