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 folks with disabilities to higher 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 outline 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 critiques distinctive boundaries 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 outline of therapy options for individuals who wouldn’t have medical insurance. We even have included assets and supplemental supplies within the appendices to help with advocacy.

Justice in Growing old strives to make the knowledge on this information as correct as doable as of the publication date (April, 2025). Nonetheless, packages serving this inhabitants are all the time evolving. To get essentially the most up-to-date info 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 prefer to thank our colleagues on the Heart for Medicare Advocacy and Neighborhood Authorized Companies for his or her important contributions to the unique information revealed in 2018.

Desk of Contents

Introduction: Why Oral Well being Issues

Oral well being is a necessary facet 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] Just like older adults throughout the nation, older adults in California expertise important 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 tooth, and almost 9 % of older adults aged 65-74 have full tooth loss.^[2] Tooth loss in nursing services is regrettably a lot increased. Over one third of nursing facility residents in California report full tooth loss and one-third of that group wouldn’t have any dentures.^[3] The truth is, the oral well being of people residing in California’s expert nursing services is considerably poorer than these residing locally on all measures together with untreated decay, skill to chew, and gum well being.^[4] Equally, people with disabilities, significantly people with developmental disabilities, expertise poorer oral well being and boundaries to therapy than individuals with out disabilities.^[5]

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

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

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

There’s settlement amongst dental specialists that poor oral well being has a considerable influence on the final well being of older adults. Tooth decay and related mouth ache result in weight reduction and poor vitamin, and exacerbate persistent 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 increased danger for coronary heart and lung illness, experiencing a stroke, having diabetic issues, and can lead to aspiration pneumonia, adopted by hospitalization and loss of life – significantly amongst nursing facility residents.^[12][13][14] Additional, for older adults with weakened immune methods, oral infections can turn into persistent.^[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 danger 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 big influence on general high quality of life. For instance, mouth ache disrupts sleep, rising the probability for melancholy and insomnia.^[18] Ongoing ache related to untreated oral well being illness will increase the probability that opioids can be prescribed and the prospect of abuse.^[19]

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

Oral well being and general well being are linked. When the physique is wholesome, the mouth is extra more likely 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 more likely 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 tooth have an effect on their skill 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 important well being, social, and financial influence, the necessity to tackle boundaries 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

Authentic Medicare

This part describes oral well being protection for people who’ve Authentic Medicare with out Medi-Cal protection. To evaluate 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 major supply of protection for adults age 65 and over and for sure people with disabilities underneath age 65.^[25] Authentic Medicare, sadly, doesn’t cowl most dental therapy. Below the regulation, dental companies “in reference to the care, therapy, filling, removing, or substitute of tooth or buildings straight supporting tooth” are particularly excluded from Medicare protection.^[26] Accordingly, routine dental care like preventive or restorative dental companies is not going to be lined by Medicare, besides in very restricted circumstances as described under.

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

Below the Medicare statute, dental protection is allowable underneath a slender 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 steering clarifying this exception and when it applies.^[28] For instance, the brand new steering 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 last rule for 2025, CMS clarified that Medicare fee could be made for dental companies which might be inextricably linked to Medicare lined dialysis companies for the therapy of end-stage renal illness. Lined companies embody dental or oral examinations acquired on an in-patient or out-patient foundation, and medically crucial diagnostic and therapy companies to eradicate an oral or dental an infection.^[30]

Whereas the exception stays slender, the clarifying steering will assist Medicare enrollees with advanced well being care wants acquire medically crucial dental companies which might be “[…] inextricably linked and considerably associated and integral to the medical success of different lined medical companies.”^[31]

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

Federal Advocacy to Increase Oral Well being Protection in Medicare

CMS Administrative Advocacy

Justice in Growing old is a part of a broad coalition of oral well being advocates and suppliers generally known as the Consortium for Medically Essential 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 medical success of different lined medical companies.”^[33] The Consortium is advocating for CMS to contemplate the incorporation of extra persistent situations together with diabetes and varied autoimmune illnesses as eligible for Medicare protection of medically crucial oral and dental therapy companies. For extra info, go to the Consortium for Medically Essential 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 Growing old in addition to a lot of different nationwide client organizations resembling Households USA, Heart for Medicare Advocacy, and AARP and oral well being organizations resembling CareQuest, have been engaged on this effort. For extra info, go to the Oral Well being part of Justice in Growing old’s web site. You can even 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, often known as 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 somewhat than by means of Authentic Medicare.^[34] Many Medicare enrollees be a part of MA plans as a way to scale back their out-of-pocket medical bills and to acquire advantages not lined by Authentic Medicare, resembling 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 resembling emergency and pressing care conditions.^[36] Usually, if members use a supplier exterior the plan’s community, together with dental suppliers, with out plan authorization, they should pay a better co-payment or the total value 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] Nonetheless, the scope of dental care lined by these plans varies broadly from plan to plan. Most plans (86%) supply intensive 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 fluctuate. Whereas few plans general (10%) cost a premium for dental protection, most plans have important value sharing, significantly for extra expensive dental companies. For instance, for restorative companies, most plans pay simply 50% of the lined service, leaving the member answerable for the remaining 50%. It’s also frequent for plans to restrict the entire quantity they are going to pay for dental care in a given 12 months – referred to 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 folks 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 may additionally qualify for Medi-Cal by means of packages which have increased earnings limits, together with the 250% working disabled program and medically needy “share of value” Medi-Cal.^[43]

There are two major 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. At the moment, almost 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 by means of the medically needy pathway and have a share of value.^[45]

Medi-Cal Dental Overview

Any particular person who’s eligible for Medi-Cal can be eligible for dental advantages by means of 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-compulsory profit underneath federal regulation.^[47] Accordingly, states wouldn’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 era grownup dental advantages have been eradicated for adults residing locally (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 Might 2014 and absolutely restored in January 2018.^[49]

Under 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.” Which means that dental advantages are supplied by means of a system that’s separate from the one that gives medical advantages. Dental advantages are delivered both by means of Payment-for-Service (FFS) or by means of 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 answerable for offering the dental profit.^[50]

Most people statewide obtain their dental advantages by means of Medi-Cal Dental fee-for-service. Which means that a person can go to any dental supplier who’s contracted with Medi-Cal Dental. As with Medi-Cal typically, 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 answerable for this position).^[51]

Medi-Cal enrollees in Los Angeles and Sacramento counties have the choice to hitch a separate Dental Managed Care (DMC) plan somewhat than obtain their dental companies by means of fee-for-service.^[52] At present, 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 absolutely 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 tooth, gum therapy, and partial and full dentures.^[61] Medi-Cal Dental additionally covers all Federally Required Grownup Companies (FRADs). FRADs are dental companies that could possibly be carried out by a medical physician (e.g., extractions).^[62] As a basic rule, Medi-Cal Dental will solely pay for the bottom value process that may appropriate the dental downside.^[63]

There are additionally extra 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 tooth (i.e., molars) when medically crucial 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 pliability 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 remedies 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 supplied to members by eligible Group Well being Employees (CHWs).^[70]

Medi-Cal Dental Protection Limitations

Medically Essential

All dental companies should be deemed medically crucial as a way to be reimbursed by Medi-Cal Dental. Medical necessity refers back to the standards used to resolve if lined companies are crucial and applicable for the therapy of the tooth, gums, and supporting buildings in keeping with professionally acknowledged requirements of follow.^[71]

Scope and Kind

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 slender 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 every day oral hygiene.^[72]

Additional, whereas dentures are solely a profit as soon as in a five-year interval, a person can acquire 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 indication 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 important medical situation requiring medical documentation from the dental supplier; or 5. for a non-catastrophic loss or misplacement, “Documentation should embody a proof of preventive measures instituted to alleviate the necessity for additional substitute.”^[73]

Dental companies are additionally restricted in kind. For instance, Medi-Cal Dental is not going to 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 Comfortable Cap

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

Accessing Medi-Cal Dental

Discovering a Supplier

To seek out suppliers, enrollees in dental managed care plans in Sacramento and Los Angeles counties can contact their plans straight 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 can be accepting new sufferers, the listing offers an choice to incorporate suppliers which might 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 answerable 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 might 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 kind 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, referred to as a therapy authorization request (TAR). You will need to notice {that a} Scientific Screening by a Scientific Screenings Dentist (CSD) is required for all TARs for members in state licensed services together with Intermediate Care Services (ICFs), and Expert Nursing Services (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 skill, or cognitive perform, pictures could also be taken as a substitute. Nonetheless, documentation explaining why x-rays weren’t taken should be included within the TAR or declare.^[88] The Supplier Handbook units forth which procedures require prior authorization and what extra 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 can be knowledgeable of the rationale why and has the choice to submit a request to reevaluate the authorization.^[90] An inventory of adjudication codes could 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 motive for the denial and supply the beneficiary the chance to enchantment the discover.^[92] Included on this information in Appendix B are the Purpose for Motion Codes summarizing 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 should pay out-of-pocket. To make sure enrollees obtain the advantages they’re eligible for, you will need to report any occasion through which a discover has not been acquired.

Co-Funds

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

Share of Value

Some Medi-Cal recipients who’re over the earnings restrict for Medi-Cal turn into eligible with a share of value (SOC) often known as a spend-down quantity. SOC eligibility features very similar to a deductible: Medi-Cal (or on this case Medi-Cal Dental) is not going to 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 totally different primarily based 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 usually are not required to rearrange NEMT to carved out companies like dental, some Medi-Cal plans decide to take action. If the Medi-Cal plan is not going to prepare 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, as a way 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 by means of prior authorization.^[96]

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

Non-Medical Transportation

If the person can journey by customary conveyance (e.g. automotive, bus, and many others.) – generally known as non-medical transportation (NMT) – however has no technique of acquiring the sort of transportation, the person’s Medi-Cal plan is required to supply NMT to dental companies. ^[98] To arrange a journey, enrollees ought to contact their plan straight 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 info to DHCSNMT@dhcs.ca.gov. They will additionally contact transportation suppliers on to schedule companies if they’ve their contact info. In contrast to NEMT, the dental supplier has no duty 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 convey 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 convey 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 Individuals with Disabilities Act and is prohibited from discriminating on the idea of race, shade, nationwide origin, intercourse (together with sexual orientation or gender identification), age or incapacity.^[100]

If a person can not discover a dentist that speaks their language, they’ve the correct 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 value (as described above).^[101] There are restricted circumstances when suppliers are allowed to enter into a non-public contract and cost enrollees. For instance, suppliers can solely cost for non-covered companies if the person understands that it’s not a lined profit and that they are going to be answerable for fee.^[102] Medi-Cal Dental suppliers who violate these guidelines are topic to sanctions as much as 3 times the Medi-Cal reimbursement charge.^[103] Medi-Cal Dental suppliers can be reported to California Dental Board or sued underneath the state’s Shopper Authorized Treatments Act and the Unfair Competitors Regulation for improper billing.^[104]

Upselling, and Dental Credit score Playing cards

Though most elementary advantages at the moment are lined underneath Medi-Cal Dental, suppliers could try and upsell uncovered companies which may be higher high quality, or new remedies 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 usually are not lined by Medi-Cal Dental and that the person can be answerable for fee for these non-covered companies. Medi-Cal Dental suppliers are inspired to supply this info in writing.^[106]

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

Nonetheless, if a person, having been knowledgeable of the above, decides to proceed with the therapy, they are going to be answerable for the price. Many suppliers will supply sufferers the chance to finance the price of these uncovered companies by means of 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. Typically, these bank cards and comparable fee 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 knowledge be supplied to them in a language they perceive earlier than signing any paperwork.

There are extra 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 comprises a deferred curiosity provision and from finishing any portion of an utility for credit score or a mortgage for the affected person or establishing an utility that’s not fully stuffed 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 duties have been supplied within the applicable threshold language. ^[109] If the supplier fails to adjust to these necessities, the person is entitled to reduction pursuant to the Shopper Authorized Treatments Act and Unfair Competitors Regulation.^[110]

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

Medi-Cal Dental Appeals and Grievances

What’s the distinction between an enchantment and grievance?

An enchantment is a proper manner of asking Medi-Cal Dental or a Medi-Cal Dental plan to vary a call relating to protection. A grievance is any grievance aside from one for a protection resolution (e.g., a supplier was impolite to the enrollee or supplied 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 rationale 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 honest listening to as quickly as they obtain a discover of motion denying a service. The listening to should 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 unique appeals course of than fee-for-service. After receiving a denial discover, the person should first file an enchantment with the dental plan. If the dental plan denies the enchantment, the person can request a state honest listening to or proceed with the plan appeals course of by requesting an inside medical evaluate (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. Nonetheless, 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 grievance 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 deal with these points. Grievances ought to be filed in situations the place an enchantment has been filed if the difficulty goes past simply a typical denial of protection, and in addition in situations the place a person has to attend lengthy durations for an appointment, acquired poor care, was handled rudely, was not supplied 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 grievance could be taken over the telephone. The person can even file a grievance by filling out a grievance kind 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 grievance and should make a conclusion inside 30 days. If the person will not be glad with the conclusion, they’ll request a state honest 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 could be resolved shortly, it’s problematic when plans don’t formally settle for and reply to a grievance since there is no such thing as a file of the incident. We due to this fact advocate that advocates insist that plans file 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 medical doctors are unlikely to look at a person’s mouth, and likewise, dental suppliers don’t all the time think about the person’s medical situation in treating their oral well being points. For instance, older adults usually take a number of medicines, a lot of which trigger dry mouth and exacerbate oral well being points. Equally, diabetes will increase the danger of infections forming within the mouth, so the necessity for normal gum therapy is essential. In a great built-in world, we’d see medical suppliers connecting their sufferers with diabetes to oral well being suppliers. Lately, 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 provided by Medi-Cal Dental to help Medi-Cal enrollees who’ve advanced 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 important 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 packages.^[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 Kind. Referrals are evaluated by the Medi-Cal Dental Buyer Service Heart.

Medi-Cal Plan Obligations

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

Program of All-Inclusive Take care of the Aged (PACE)

The Program of All-Inclusive Take care of 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 stage of care; and be capable of safely dwell locally.^[117] PACE plans present all Medicare and Medi-Cal lined companies, together with lined dental companies, at a PACE website. If the PACE website is unable to carry out a lined dental service on the website, the person can be referred to a group supplier.

Business Plans & Dental Financial savings Plans

Business Plans

Older adults who usually are not eligible for Medi-Cal, and who’ve the monetary means, could need to think about buying a business dental plan. There are frequent options with these plans that people ought to examine when purchasing for protection.^[118] These plans will embody prices for month-to-month premiums and an annual deductible that should be met earlier than the plan pays for companies. Plans virtually all the time may even have a low annual profit most (e.g. starting from $1,000 – $2,000).^[119] One other frequent function 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 is not going to be lined at 100%. As a substitute, the person can be answerable 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 business dental plans for shoppers and suppliers in California. For instance, Meeting Invoice 1048 and Meeting Invoice 952 are essential to uplift as each took impact January 2025. Meeting Invoice 1048 prohibits denials primarily based on pre-existing situations, prohibits plans within the giant group market from imposing ready durations, and requires state regulatory evaluate of the premiums charged by dental plans to assist defend 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 by means of 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 usually are not actually plans in any respect within the conventional sense. Somewhat, a person pays an annual payment after which receives reductions from suppliers who’ve agreed to just accept the plan. The reductions fluctuate 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. In contrast to a business plan, these financial savings plans sometimes wouldn’t have annual profit maximums or ready durations. Once more, it is crucial for people to check plans for value, 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 boundaries to accessing care due to their twin standing. The first boundaries duals face in accessing oral well being care happen once they decide to enroll in a Medicare Benefit (MA) plan that gives dental protection as a supplemental profit. They could encounter difficulties due to how the MA plan interacts with their Medi-Cal Dental protection. Twin eligible people ought to evaluate their MA plan dental protection fastidiously and perceive the dental protection supplied by the plan. MA dental supplemental advantages are sometimes not complete. Under 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 major on Medicare lined companies, and Medicaid protection pays as a secondary medical insurance payor.^[123] Therefore, Medi-Cal is often all the time the payor of final resort. Which means that for a dually eligible particular person enrolled in an MA plan that features dental protection, the MA plan ought to be major with few exceptions. Accordingly, dually eligible people ought to see dental suppliers which might 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 instances are improperly billed for companies which might be lined by Medi-Cal Dental. In these conditions, dually eligible people are nonetheless shielded from 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 provided dental advantages which might 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) supplied by the identical firms that supplied 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 answerable for delivering all Medicare and Medi-Cal advantages underneath one plan (with exceptions, resembling carved-out dental advantages). In 2023, Medi-Medi plans have been provided solely within the seven counties listed above. In 2024, Medi-Medi plans have been prolonged to 5 extra counties together with Fresno, Kings, Madera, Sacramento, and Tulare. By 2026, these plans can be obtainable to twin eligible Californians in extra counties.^[131]

Dental advantages proceed to be carved-out from Medi-Medi plans, which implies 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 solely 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 final inhabitants. That is true even if nursing facility residents retained full dental advantages underneath Medi-Cal once they have been eradicated for adults residing locally in 2009.^[136] Whereas protection is complete, nursing facility residents face totally different boundaries to entry. For instance, residents obtain their oral well being therapy primarily throughout the partitions of the nursing facility since residents have a harder time searching for therapy locally. The result’s that the majority residents solely obtain therapy once 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 supplied by nursing dwelling services serving communities of shade,^[137] oral well being care stays an fairness challenge that requires sustained advocacy. We hope with sturdy advocacy we are able to enhance oral well being care entry throughout all California nursing properties together with people who serve communities of shade. Listed below 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 important change within the resident’s situation.^[139] Nursing services are required to finish the Minimal Knowledge Set (MDS) – a federally required medical 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 skill to swallow and their dietary standing, and Part L particularly covers oral well being issues, together with damaged or loosely becoming dentures, no pure tooth, mouth ulcers or lesions, apparent cavities, damaged tooth or unfastened tooth, 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 power 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 should be included within the care planning course of.^[141] In follow, this usually implies that nursing services will prepare for a dentist to go to a facility frequently, and residents who’re experiencing acute dental points can be signed as much as be seen. However services are required to do extra. Particularly, pursuant to federal regulation, services are straight answerable for the oral well being wants of their residents.^[142]

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

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

Nursing services usually are 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 by means of Medicare or Medi-Cal.^[144]

Oral Hygiene

Many residents in nursing services are unable to hold out the actions required to take care of their oral well being. For these residents, nursing services are required to supply companies resembling brushing of the tooth, cleansing dentures, and cleansing the mouth and tongue to take care of 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] Services 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 power’s duty and prohibits the power from charging the resident for the loss or harm when the power is at fault. Services additionally should make a referral to a dental supplier inside three (3) enterprise days when dentures are misplaced or broken. ^[148]

Residential Care Services for the Aged

Residential Care Services for the Aged (RCFE), additionally known as “Assisted Residing” or “Board and Care” are non-medical services for older adults who require help with actions of every 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 Services for the Developmentally Disabled

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

Different Oral Well being Therapy Choices

Some older adults wouldn’t have entry to any dental protection or solely have restricted protection by means of Medicare or business plans. There are a variety of choices obtainable that, whereas not complete or all the time obtainable, are price exploring.

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

Group well being facilities settle for each Medi-Cal and Medicare in addition to most business insurance coverage choices. CHCs serve all sufferers no matter their skill to pay, which makes them a horny choice for older adults searching for dental care who wouldn’t have protection by means of 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 group well being heart of their space to find out how and when the CHC can greatest serve them, and ensure what dental companies are supplied.

Group 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 locally, searching for care at a group well being heart could also be an choice.

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 value by means of the VA Dental Insurance coverage Program.^[154]

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

Dental Colleges

There are seven dental colleges in California.^[155] These colleges usually present therapy to populations in want. Companies are normally supplied 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 you will need to contact the varsity to find out whom the varsity serves and whether or not the therapy sought is a service the varsity gives. See Appendix A for a listing of colleges and make contact with info.

Pop-Up Clinics

There are efforts to bridge gaps in entry to dental care by offering care at giant pop-up clinics. These clinics are typically staffed by volunteers and supply a spread of various companies at no cost. The pop-up clinics are normally arrange in a public area. Since these occasions are normally crowded with lengthy waits, additionally it is essential to do a little analysis earlier than touring to a pop-up clinic to make sure the companies the person wants are being provided. Pop-up clinics could be situated by means of 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 vital step in guaranteeing low-income older adults have pretty complete protection by means of Medi-Cal Dental, boundaries to accessing these advantages and high quality therapy are important. It’s our intention that this information will assist advocates navigate the system and empower them to establish and tackle systemic boundaries to oral healthcare.

Appendix A – Sources

Shopper Help Sources

Under is a listing of client help packages 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 Sources

State Companies

Coalitions and Federal Sources

Dental Colleges

• 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 Faculty of Dental Drugs, Pomona
• California Northstate College, Faculty of Dental Drugs

Appendix B – Medi-Cal Dental Purpose for Motion Codes

Purpose for Motion Codes

01 Your help code covers emergency companies solely.

02 Info 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 variation was primarily based on the knowledge submitted by your dentist regarding your present dental situation or on program pointers.

04 Our information present this service(s) or an analogous 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 should 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 unique therapy plan.

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

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

09 X-rays present that the tooth doesn’t meet the necessities for a crown. At the least 51% of the tooth should be lacking and/or decayed. The tooth could also be restored with a filling.

10 X-rays present that the tooth/tooth 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 info we acquired from our screening examination, you wouldn’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 knowledge submitted by your dentist and/or acquired 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 info we acquired from a screening examination, it has been decided that the tooth/tooth has/have worn down naturally or you’ve bruxism (tooth grinding). The requested service will not be a good thing about this system to revive tooth worn down naturally or by bruxism or that wouldn’t have decay or haven’t fractured.

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

16 Our information present that the tooth has been restored with a suitable 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 advocate a unique therapy.

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

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

20 Root canal therapy should be satisfactorily accomplished earlier than a crown could be thought of.

21 Tooth will not be absolutely developed. Your dentist could possibly advocate a unique therapy.

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

23 A stayplate is usually a profit solely to switch a lacking everlasting entrance tooth.

24 X-rays present that extra extractions are crucial earlier than the therapy plan could be authorized; please contact your dentist.

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

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

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

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

29 Deep scaling and gum remedies usually are not a profit for kids, aside from circumstances the place medicines have prompted 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 info acquired from a screening examination, your current denture is passable at this time.

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

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

35 Throughout your screening examination, you indicated you don’t want extractions or some other 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 info we acquired from our screening examination, you want extra therapy out of your dentist earlier than the process could be thought of.

39 X-rays present there may be not sufficient area current for the requested false tooth.

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

41 Primarily based on x-rays and/or confirmed by info we acquired from our screening examination, we have now decided that you’ve got bruxism (tooth grinding). The therapy of bruxism will not be a good thing about 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 advocate a unique therapy to your situation.

43 The process requested is not going to appropriate your dental downside. Your dentist could possibly advocate a unique therapy to your situation.

44 Primarily based on info acquired out of your dentist, it’s decided that the requested service is for beauty causes solely. Companies for beauty functions solely usually are not a good thing about this system.

45 Your present denture could 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 fee or authorization.

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

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

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 Take care of Folks 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 Individuals,” (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,” At the moment’s Geriatric Drugs, 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, “Massive Examine Hyperlinks Gum Illness with Dementia,” (July 9, 2020); M. Beydoun et al., “Scientific and Bacterial Markers of Periodontitis and Their Affiliation with Incident All-Trigger and Alzheimer’s Illness Dementia in a Massive 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 The best way to Determine, Deal with, Refer and Apply Legal guidelines and Laws in Your Observe,” 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 Properly-Being in California,” (2015). ↑
24. HHS, supra notice 12 at 3. ↑
25. See Facilities for Medicare and Medicaid Companies, “Authentic 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 Fee Rule Strengthening Entry to Behavioral Well being Companies and Complete-Particular person Care,” (Nov. 1, 2022) (Accessed February 7, 2025). ↑
30. CMS, “Truth Sheets: Calendar 12 months (CY) 2025 Medicare Doctor Payment Schedule Remaining 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 Info,” (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 Regulation & Poverty, “Getting and Retaining 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 Folks with Disabilities,” Justice in Growing old (March 2023) p. 8. ↑
46. See DHCS, “Medi-Cal Dental Supplier Handbook,” § 4 at 5 (2024), (Accessed February 7, 2025). ↑
47. Medicaid, “Necessary & Non-obligatory Medicaid Advantages,” (Accessed August 4, 2024). ↑
48. Federally Certified Well being Facilities (FQHCs) sued to power 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 by means of 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 (Might 31,2024) (Accessed July 10, 2024). ↑
56. See DHCS, “Dental Knowledge Studies,” (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 Charge Overview,” 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, “Scientific Screening Dentist Handbook,” v. 1.1, pp. 8 and 25, (August 22, 2024). Notice the handbook 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 handbook 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, (Might 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,” (Might 18, 2022), (Accessed February 8, 2025). ↑
99. DHCS, supra notice 95. ↑
100. See Individuals 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. Shopper Monetary Safety Bureau, “Medical Credit score Playing cards and Financing Plans,” (Might 2023) (Accessed February 8, 2025); For extra info, see Nationwide Shopper Regulation Heart, “Coping with Medical Debt: Shopper 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 Take care of 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 Social gathering 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: Info 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, “Info 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 Checklist,” (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 Person’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 Group 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 Colleges of California, see Dental Board of California “Checklist of California authorized dental colleges,” (Accessed August 1, 2024). ↑

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