Effective for dates of service on or after January 1, 2022, the Department of Health Care Services (DHCS) will implement the California Advancing and Innovating Medi-Cal (CalAIM) dental initiatives statewide. CalAIM dental initiatives are based on the successful outcomes of the Dental Transformation Initiative (DTI), which was implemented in certain counties from 2016 to 2021 under the 2020 Medi-Cal 1115 Waiver.
CalAIM dental initiatives include pay-for-performance payments for preventive services and continuity of care/ establishing a dental home, and two new program benefits: caries-risk assessment (CRA) bundle for children ages zero to six and application of caries arresting medicament silver diamine fluoride (SDF).
For the pay-for-performance payments, Indian Health Services, Memorandum of Agreement (IHS-MOA), Federally Qualified Health Centers (FQHCs), Tribal FQHCs, and Rural Health Clinics (RHCs) also referred to as Safety Net Clinics (SNCs), must submit detailed claims data to the Dental Fiscal Intermediary (FI) following the guidelines below for the new CRA and SDF benefits. In addition to the pay-for-performance payments, dental services will be reimbursable at the clinic’s established per-visit rate via the Medi-Cal FI using the billing instructions in the Rural and Indian Health Provider, Tribal FQHC Manuals.
- Preventive services, paid at 75% of the standard Schedule of Maximum Allowances (SMA) fee for each paid preventive service
- The Current Dental Terminology (CDT) procedures eligible for this pay-for-performance payment are as follows:
- Ages 0 to 20:
- D1120, prophylaxis, child
- D1206, topical application of fluoride varnish
- D1208, topical application of fluoride - excluding varnish
- D1351, sealant - per tooth
- D1352, preventive resin restoration in a modern to high caries risk patient, permanent tooth
- D1510, space maintainer – fixed, unilateral, per quadrant
- D1516, space maintainer – fixed, bilateral, maxillary
- D1517, space maintainer – fixed, bilateral, mandibular
- D1526, space maintainer – removable, maxillary
- D1527, space maintainer – removable, mandibular
- D1551, re-cement or re-bond bilateral space maintainer – maxillary
- D1552, re-cement or re-bond bilateral space maintainer – mandibular
- D1553, re-cement or re-bond unilateral space maintainer – per quadrant
- D1556, removal of fixed unilateral space maintainer – per quadrant
- D1557, removal of fixed bilateral space maintainer – maxillary
- D1558, removal of fixed bilateral space maintainer – mandibular
- D1575, distal shoe space maintainer, fixed, unilateral – per quadrant
- Ages 21 or older:
- D1320, tobacco counseling for the control and prevention of oral disease
- D1999, unspecified preventive procedure, by report
- Continuity of care, paid at $55 annually for each beneficiary who receives at least one annual dental exam for two or more years in a row at the same dental service office location (dental home).
- The CDT procedures eligible for this pay-for-performance payment are as follows:
- D0120, periodic oral evaluation – established patient
- D0145, oral evaluation for a patient under three years of age and counseling with primary caregiver
- D0150, comprehensive oral evaluation – new or established patient
- Pay-for-performance payments are issued to providers once per month and inclusive of both preventive services and continuity of care.
- To earn pay-for-performance payments, SNCs must send qualifying paid claims data (including CDT codes for services rendered) to the Dental FI for processing and payment. Claims must be submitted within 12 months of the date of service to qualify for payment. Claims may be submitted electronically through the Electronic Data Interchange (EDI) process, or the proprietary paper form submission process described on the CalAIM Dental web page. The proprietary mailing address is:
Medi-Cal Dental Operations
SNC Paper Encounter Submissions
PO Box 13189
Sacramento, CA 95813-3189
The new benefits described below are reimbursable at the clinic’s established per-visit rate.
- CRA and nutritional counseling bundle for children ages zero to six.
- All providers are required to take and complete the Treating Young Kids Everyday (TYKE) training hosted by the California Dental Association to provide CRA treatment to patients. If a provider has previously successfully completed the TYKE training for DTI, they do not have to retake the training.
- Certification of completion must remain on file for audit purposes.
- Providers must use the CRA forms, which are posted on the DHCS CalAIM Dental These forms must remain on file for audit purposes.
- SDF application for children ages zero to six and for individuals of all ages for whom non-restorative caries treatment is optimal (including the Department of Developmental Services (DDS) population, those living in Skilled Nursing Facilities/Intermediate Care Facilities [SNFs/ICFs], or those with another demonstrated medical necessity).
Providers are reminded that treatment plans should be patient-centered and equitable. Per Medi-Cal Dental policy, providers shall minimize the number of dental visits for the patient when applicable, feasible, and consistent with the standard of care. Documentation should follow requirements established in the Medi-Cal Dental Provider Handbook and Manual of Criteria and should indicate the medical necessity of any additional visits required for treatment. In most cases, SDF/caries arresting medicaments should be applied during the regular dental exam, prophylaxis appointments, or during CRA appointments.