Report 2014-130 Recommendation 1 Responses

Report 2014-130: California Department of Health Care Services: It Should Improve Its Administration and Oversight of School‑Based Medi-Cal Programs (Release Date: August 2015)

Recommendation #1 To: Health Care Services, Department of

To ensure that it provides claiming units with reasonable opportunities to address concerns with its decisions or actions, Health Care Services should, within three months, begin preparing regulations to establish and implement a formal appeals process that allows claiming units to directly appeal Health Care Services' decisions.

Annual Follow-Up Agency Response From August 2019

There is no change to DHCS' previous response. DHCS issued PPL #14-006 on April 4, 2014 outlining the current appeal process which is applicable to all program stakeholders. The PPL is also posted on the DHCS/SMAA website. DHCS will not implement.

California State Auditor's Assessment of Annual Follow-Up Status: Will Not Implement

Annual Follow-Up Agency Response From November 2018

There is no change to DHCS' previous response. DHCS issued the Policy and Procedures Letter (PPL) #14-006 on April 4, 2014 outlining the current appeal process. The PPL is also posted on the DHCS/SMAA website.

California State Auditor's Assessment of Annual Follow-Up Status: Will Not Implement

Annual Follow-Up Agency Response From September 2017

There is no change to DHCS' previous response. DHCS issued the Policy and Procedures Letter (PPL) #14-006 on April 4, 2014 outlining the current appeal process. The PPL is also posted on the DHCS/SMAA website.

California State Auditor's Assessment of Annual Follow-Up Status: Will Not Implement

1-Year Agency Response

DHCS currently has an appeals process in place and it has been distributed to all program stakeholders and posted to the School-Based Medi-Cal Administrative Activities (SMAA) web page that specifically addresses appeals.

California State Auditor's Assessment of 1-Year Status: Will Not Implement

As we mention on pages 27 and 28 of our audit report, Health Care Services has offered claiming units, including local educational agencies, no formal opportunity to appeal its decisions to deny reimbursement claims.

6-Month Agency Response

DHCS does not contract with the Local Educational Agency (LEAs) directly. LEAs contract with their local Local Educational Consortia (LEC) or Local Governmental Agency (LGA) and DHCS contracts with the LEC/LGAs. Therefore, any disputes with DHCS directives must first be addressed at the LEC/LGA level before the issue can be elevated to DHCS. If there is no resolution between the LEA and LEC/LGA, the appeal can be directed to DHCS to work with both the LEA and the LEC/LGA to resolve.

DHCS currently has a formal appeals process that has been distributed to all program stakeholders and posted to the School-Based Medi-Cal Administrative Activities (SMAA) web page that specifically addresses appeals.

California State Auditor's Assessment of 6-Month Status: Will Not Implement

As we mention on pages 27 and 28 of our audit report, Health Care Services has offered claiming units, including local educational agencies, no formal opportunity to appeal its decisions to deny reimbursement claims.

60-Day Agency Response

DHCS disagrees with the recommendation.

DHCS does not contract with the LEAs directly. LEAs contract with their local LEC or LGA and DHCS contracts with the LEC/LGAs. Therefore, any disputes with DHCS directives must first be addressed at the LEC/LGA level before the issue can be elevated to DHCS. If there is no resolution between the LEA and LEC/LGA, the appeal can be directed to DHCS to work with both the LEA and the LEC/LGA to resolve.

DHCS currently has a formal appeals process that has been distributed to all program stakeholders and posted to the SMAA web page that specifically addresses appeals.

California State Auditor's Assessment of 60-Day Status: Will Not Implement

As we mention on pages 27 and 28 of our audit report, Health Care Services has offered claiming units, including local educational agencies (LEAs) no formal opportunity to appeal its decisions to deny reimbursement claims. Furthermore, no claiming units have ever used Health Care Services' current process, whereby they can appeal decisions made by local educational consortia and local governmental agencies.

All Recommendations in 2014-130

Agency responses received are posted verbatim.