As of May 1, 2014, limited dental services will be included for adults, 21 years and older, that are on Medi-Cal. Adult dental Medi-Cal services were removed during the California budget crisis in 2009. Some counties may require adults to enroll in a dental manage care plan while others will offer a Fee-For-Service program. The Denti-Cal adult services will be the same whether they are obtained through a plan or through a Denti-Cal participating dentist or clinic. The challenge for adults in rural counties will be finding a dentist that accepts Denti-Cal.
Medi-Cal offers limited adult dental services
In the fall of 2013, the Department of Health Care Services sent out a letter notifying the managed care dental plans that adult services were to be restored as of May 1, 2014. The letter outlined the list of services that would be allowed of Medi-Cal beneficiaries who were over 21 years of age.
Dental managed care plans
In Sacramento County it is mandatory that Medi-Cal recipients enroll in a managed dental care program if they want services. Los Angeles County also offers the dental managed care plans, but enrollment is voluntary. A Denti-Cal staff member indicated that Riverside and San Bernardino counties would also be offering adult dental managed care plans. Members of the dental managed care plans will have a list of dentists to select from and will be issued a separate card for the plan in addition to the Medi-Cal card.
Fee-for-Service and Share of Cost
The Fee-For-Service (FFS) Denti-Cal program allows the adult beneficiary to visit any dentist or clinic that is in the Medi-Cal dental program. The Medi-Cal eligibility and along with the individual’s identity will need to be verified with each office visit. In addition, there may be a Share of Cost (SOC) that might have to be paid for dental services. The SOC can vary by county and can also include Medi-Cal health benefits. In other words, there may be a SOC for both the health and dental, but if the monthly total was met by a beneficiary paying for a health care service, then the dentist won’t have to collect it.
Denti-Cal Handbook for Dentists
Providers may not submit a claim to, or demand or otherwise collect reimbursement from, a Medi-Cal beneficiary, or from other persons on behalf of the beneficiary, for any service (other than Share of Cost).
If Medi-Cal eligibility is verified, the provider may not treat the beneficiary as a private-pay beneficiary to avoid billing the beneficiary’s insurance, obtaining prior authorization (when necessary) or complying with any other program requirement. In addition, upon obtaining eligibility verification, the provider cannot bill the beneficiary for all or part of the charge of a Medi-Cal covered service except to collect the Medi-Cal copayment or SOC. Providers cannot bill beneficiaries for private insurance cost-sharing amounts such as deductibles, co-insurance or copayments.
Share of Cost (SOC)
If the Medi-Cal eligibility verification system indicates a beneficiary has a Share of Cost (SOC), the SOC must be met before a beneficiary is eligible for Medi-Cal benefits. Refer to the applicable transaction manual for directions on applying SOC.
Maximum annual dental benefit
The maximum calendar benefit an adult can receive in dental services is $1,800. That is the maximum amount that Denti-Cal will pay participating dentists on behalf of an adult Medi-Cal recipient. After the maximum amount is reached, the dentist can continue dental services at usual and customary rates as long as the patient agrees to the charges.
Denti-Cal dentist search
Instead of a dentist search, it might be called a dentist hunt. (Denti-Cal dentist search link) In some counties there are no independent dentists accepting Denti-Cal, such as Yuba, when I searched on the website on April 30. There were, however, three different clinic locations: Peach Tree Clinic on Parkard Ave, Peach Tree on Lindhurst and the AMPLA Health Lindhurst in Olivehurst. Dental care is a great and necessary health benefit, but if there are no providers, there is no dental care.