## Facts

- California administered Medicaid medical benefits through Medi-Cal and dental benefits through Denti-Cal, with reimbursement rates set by the state.
- Virginia Clark and a class of Medi-Cal/Denti-Cal beneficiaries alleged they could not obtain meaningful dental care because too few dentists would treat Denti-Cal patients.
- Evidence showed fewer than 40% of licensed California dentists treated any Denti-Cal recipients, and many participating dentists limited the number of Denti-Cal patients or services provided.
- Plaintiffs contended low reimbursement rates and administrative burdens reduced provider participation and forced beneficiaries to rely on limited or emergency-only care.
- Plaintiffs sought declaratory and injunctive relief requiring the state to bring Denti-Cal into compliance with federal Medicaid requirements, including the “equal access” requirement.

## Issues

1. Whether California’s Denti-Cal payment rates and related policies violated 42 U.S.C. § 1396a(a)(30)(A) by failing to ensure payments sufficient to enlist enough dental providers so that services were available to beneficiaries to the same extent as to the general population.
2. Whether other aspects of Denti-Cal (including limitations and administration affecting covered dental services, particularly for children) violated additional Medicaid requirements governing the adequacy and scope of services.

## Decision

- The court granted plaintiffs’ motion for partial summary judgment in part and denied it in part.
- The court held California’s Denti-Cal reimbursement structure violated the Medicaid “equal access” provision, 42 U.S.C. § 1396a(a)(30)(A), because payment levels were not sufficient to enlist enough dentists to provide comparable access.
- The court ordered injunctive relief requiring the state to revise its dental reimbursement methods and/or rates to comply with § 1396a(a)(30)(A).
- The court denied or did not resolve other requested relief where factual disputes remained or where plaintiffs sought broader rulings than the court was prepared to enter on summary judgment.

## Legal Principles

- Under Rule 56, summary judgment is appropriate when there is no genuine dispute of material fact and the movant is entitled to judgment as a matter of law.
- Medicaid’s equal access provision, 42 U.S.C. § 1396a(a)(30)(A), requires state plans to use payment methods that are consistent with efficiency, economy, and quality of care and that set payments sufficient to enlist enough providers so covered services are available to beneficiaries at least to the extent available to the general population in the same geographic area.
- Compliance with § 1396a(a)(30)(A) turns on practical access and provider participation, not merely the formal existence of covered benefits.
- Provider participation evidence may be used to assess whether payment levels are “sufficient to enlist enough providers,” and persistent low participation can support a finding of noncompliance.

## Conclusion

The court found that California’s Denti-Cal reimbursement approach produced inadequate provider participation and therefore violated Medicaid’s equal access requirement, warranting injunctive relief to reform payment methods, while declining to grant summary judgment on other asserted deficiencies in the dental program.


Clark v. Kizer, 758 F. Supp. 572 (E.D. Cal. 1990)