Report 2018-111 All Recommendation Responses
Report 2018-111: Department of Health Care Services: Millions of Children in Medi-Cal Are Not Receiving Preventive Health Services (Release Date: March 2019)
Recommendation for Legislative Action
To improve children's access to preventive health services, the Legislature should amend state law to direct DHCS to modify its criteria for evaluating plans' alternative access standards requests to include not only whether plans' efforts were reasonable but also whether the resulting times and distances are reasonable to expect a Medi-Cal beneficiary to travel.
Description of Legislative Action
AB 1642 (Chapter 465, Statutes of 2019) requires DHCS, when evaluating an alternative access standard request, to evaluate and determine whether the resulting time and distance is reasonable to expect a beneficiary to travel to receive care.
- Legislative Action Current As-of: October 2019
California State Auditor's Assessment of 6-Month Status: Legislation Enacted
Description of Legislative Action
AB 1642 (Wood) would require, in part, a Medi-Cal managed care plan to provide to DHCS additional information in its request for the alternative access standards, including a description of the reasons justifying the alternative access standards.
- Legislative Action Current As-of: May 2019
California State Auditor's Assessment of 60-Day Status: Legislation Introduced
Recommendation for Legislative Action
To improve children's access to preventive health services, the Legislature should amend state law to require any plan unable to meet the criteria for time and distance access standards to allow its affected members to obtain services outside of the plan's network.
Description of Legislative Action
As of March 14, 2022, the Legislature has not taken action to address this specific recommendation.
- Legislative Action Current As-of: March 2022
California State Auditor's Assessment of Annual Follow-Up Status: No Action Taken
Description of Legislative Action
As of March 14, 2021, the Legislature has not taken action to address this specific recommendation.
- Legislative Action Current As-of: March 2021
California State Auditor's Assessment of Annual Follow-Up Status: No Action Taken
Description of Legislative Action
As of March 14, 2020, the Legislature has not taken action to address this specific recommendation.
- Legislative Action Current As-of: March 2020
California State Auditor's Assessment of 1-Year Status: No Action Taken
Description of Legislative Action
The Legislature has not taken action to address this specific recommendation. However, AB 1642 requires a Medi-Cal managed care plan that has received approval from DHCS to utilize an alternative access standard to arrange for Medi-Cal covered transportation for the enrollee, as determined by DHCS, and to inform affected members of the approved alternative access standards.
- Legislative Action Current As-of: October 2019
California State Auditor's Assessment of 6-Month Status: No Action Taken
Description of Legislative Action
AB 1642 would require a Medi-Cal managed care plan that has received approval from DHCS to utilize an alternative access standard to assist an enrollee who would travel farther than the established time and distance standards in obtaining an appointment with an appropriate out-of-network provider within established appointment time standards.
- Legislative Action Current As-of: May 2019
California State Auditor's Assessment of 60-Day Status: Legislation Introduced
Recommendation for Legislative Action
To improve children's access to preventive health services, the Legislature should amend state law to direct DHCS to require plans to inform members allowed to obtain services outside of the plan's network that they may do so.
Description of Legislative Action
As of March 14, 2022, the Legislature has not taken action to address this specific recommendation.
- Legislative Action Current As-of: March 2022
California State Auditor's Assessment of Annual Follow-Up Status: No Action Taken
Description of Legislative Action
As of March 14, 2021, the Legislature has not taken action to address this specific recommendation.
- Legislative Action Current As-of: March 2021
California State Auditor's Assessment of Annual Follow-Up Status: No Action Taken
Description of Legislative Action
As of March 14, 2020, the Legislature has not taken action to address this specific recommendation.
- Legislative Action Current As-of: March 2020
California State Auditor's Assessment of 1-Year Status: No Action Taken
Description of Legislative Action
The Legislature has not taken action to address this specific recommendation. However, AB 1642 requires a Medi-Cal managed care plan that has received approval from DHCS to utilize an alternative access standard to arrange for Medi-Cal covered transportation for the enrollee, as determined by DHCS, and to inform affected members of the approved alternative access standards.
- Legislative Action Current As-of: October 2019
California State Auditor's Assessment of 6-Month Status: No Action Taken
Description of Legislative Action
AB 1642 would require a Medi-Cal managed care plan that has received approval from DHCS to utilize an alternative access standard to assist an enrollee who would travel farther than the established time and distance standards to inform all members in mailings of specified related matters, including the Medi-Cal managed care plan's alternative time and distance standards and how to access Medi-Cal covered transportation.
- Legislative Action Current As-of: May 2019
California State Auditor's Assessment of 60-Day Status: Legislation Introduced
Recommendation for Legislative Action
To improve children's access to preventive health services, the Legislature should amend state law to require plans unable to meet the criteria for time and distance access standards to assist members in locating a suitable out-of-network provider.
Description of Legislative Action
As of March 14, 2022, the Legislature has not taken action to address this specific recommendation.
- Legislative Action Current As-of: March 2022
California State Auditor's Assessment of Annual Follow-Up Status: No Action Taken
Description of Legislative Action
As of March 14, 2021, the Legislature has not taken action to address this specific recommendation.
- Legislative Action Current As-of: March 2021
California State Auditor's Assessment of Annual Follow-Up Status: No Action Taken
Description of Legislative Action
As of March 14, 2020, the Legislature has not taken action to address this specific recommendation.
- Legislative Action Current As-of: March 2020
California State Auditor's Assessment of 1-Year Status: No Action Taken
Description of Legislative Action
The Legislature has not taken action to address this specific recommendation. However, AB 1642 requires a Medi-Cal managed care plan that has received approval from DHCS to utilize an alternative access standard to arrange for Medi-Cal covered transportation for the enrollee, as determined by DHCS, and to inform affected members of the approved alternative access standards.
- Legislative Action Current As-of: October 2019
California State Auditor's Assessment of 6-Month Status: No Action Taken
Description of Legislative Action
AB 1642 would require a Medi-Cal managed care plan that has received approval from DHCS to utilize an alternative access standard to assist an enrollee who would travel farther than the established time and distance standards to arrange for Medi-Cal covered transportation for the enrollee, as necessary.
- Legislative Action Current As-of: May 2019
California State Auditor's Assessment of 60-Day Status: Legislation Introduced
Recommendation for Legislative Action
To improve the health of California's children, the Legislature should direct DHCS to implement financial incentives, such as a pay-for-performance program, designed to help ensure that plans are more consistently providing preventive services to children in Medi-Cal. To the extent DHCS can demonstrate that additional funding is necessary to operate such a program, the Legislature should increase funding specifically for that purpose.
Description of Legislative Action
SB 773 (Roth, 2022) would, commencing with the January 1, 2022, rating period, and through December 31, 2024, require DHCS to make incentive payments to qualifying Medi-Cal managed care plans that meet predefined goals and metrics associated with targeted interventions, rendered by school-affiliated behavioral health providers, that increase access to preventive, early intervention, and behavioral health services for children enrolled in kindergarten and grades 1 to 12. The bill would require DHCS to consult with certain stakeholders on the development of interventions, goals, and metrics, to determine the amount of incentive payments, and to seek any necessary federal approvals. The bill would condition the issuance of incentive payments on compliance with federal requirements and the availability of federal financial participation. Alternatively, if federal approval is not obtained, the bill would authorize DHCS to make incentive payments on a state-only funding basis, but only to the extent DHCS determines that federal financial participation for the Medi-Cal program is not otherwise jeopardized. As of March 14, 2022, this bill is pending in the Senate.
- Legislative Action Current As-of: March 2022
California State Auditor's Assessment of Annual Follow-Up Status: Legislation Introduced
Description of Legislative Action
As of March 14, 2021, the Legislature has not taken action to address this specific recommendation.
- Legislative Action Current As-of: March 2021
California State Auditor's Assessment of Annual Follow-Up Status: No Action Taken
Description of Legislative Action
As of March 14, 2020, the Legislature has not taken action to address this specific recommendation.
- Legislative Action Current As-of: March 2020
California State Auditor's Assessment of 1-Year Status: No Action Taken
Description of Legislative Action
AB 537 (Arambula) would have required, commencing January 1, 2022, a Medi-Cal managed care plan to meet a minimum performance level (MPL) that improves the quality of health care and reduces health disparities for enrollees. The bill would have required DHCS to establish both a quality assessment and performance improvement program and a value-based financial incentive program to ensure that a Med-Cal managed care plan achieves an MPL. This bill was held in the Assembly Appropriations Committee.
- Legislative Action Current As-of: October 2019
California State Auditor's Assessment of 6-Month Status: Legislation Proposed But Not Enacted
Description of Legislative Action
AB 537 (Wood) would require DHCS to develop a plan for a value-based financial incentive program to reward a high-performing Medi-Cal managed care plan that meets performance targets that demonstrate health care quality improvement and health disparities reduction. DHCS would be required to utilize the results of the quality assessment and performance improvement program to develop a publicly reported Quality Rating System for Medi-Cal plans, and establish a public stakeholder process in the planning, development, and ongoing oversight of the quality assessment and performance improvement program and the value-based financial incentive program.
- Legislative Action Current As-of: May 2019
California State Auditor's Assessment of 60-Day Status: Legislation Introduced
Recommendation #6 To: Health Care Services, Department of
To increase access to preventive health services for children in areas where they are needed most, DHCS should identify by September 2019 where more providers who see children are needed and propose to the Legislature funding increases to recruit more providers in these areas.
Annual Follow-Up Agency Response From September 2022
There is no agency response for this update. Government Code section 8546.1(d) authorizes the California State Auditor to conduct follow-up audit work on statutorily mandated or legislatively required financial and performance audits. Our office followed up on this March 2019 audit to assess DHCS's status regarding implementation of the eight outstanding recommendations from this report. Below is our assessment of the status of this recommendation based on work we performed during the follow-up audit. All future updates for this recommendation will be posted under the follow-up audit (2022-502).
- Estimated Completion Date:
California State Auditor's Assessment of Annual Follow-Up Status: Will Not Implement
DHCS stated in its response to the follow-up audit that it will not implement this recommendation because it asserts that broader workforce recruitment is beyond its purview. However, as the state agency solely responsible for administering Medi-Cal, DHCS has the authority to implement this recommendation. Without a targeted effort by DHCS to increase the number of Medi-Cal providers, children in Medi-Cal will likely continue to face limited access to care.
Annual Follow-Up Agency Response From October 2021
As described in the 2020 Annual Update, DHCS obtained network recruitment strategies from two Regional Model Medi-Cal MCPs, Anthem and California Health & Wellness. The Regional Model MCPs identified their approaches on outreach to expand their networks, such as focused communications to specialists, providers that are contracted with other MCPs, and providers in bordering counties outside the MCPs' counties. They have also encouraged their commercial providers to offer services to Medi-Cal beneficiaries and have used provider incentives to attract new providers in the network, including offering contracts above standard Medi-Cal rates. Further, to promote provider relationships, the MCPs have established designated teams to onboard new providers, address provider concerns, and offer continuous support. Lastly, both MCPs have expanded their use of telehealth services. These strategies aim to improve access to care for their Medi-Cal members.
California State Auditor's Assessment of Annual Follow-Up Status: Will Not Implement
It remains unclear why DHCS disagrees with this recommendation that would proactively address the problem of California children not receiving preventive services in areas where there is a lack of Medi-Cal providers. Instead, DHCS continues to shift responsibility to private managed care plans (MCPs).
Annual Follow-Up Agency Response From November 2020
DHCS continues to disagree with the recommendation. DHCS does agree increasing the number of physicians who practice in Regional Model counties is beneficial for all health care delivery systems.
Specific to Medi-Cal providers, Proposition 56 provided a one-time allocation of $340 million for a loan repayment program for recently graduated physicians and dentists. The selection of physicians and dentists for participation is based on eligibility criteria and prioritizing individuals agreeing to work in geographic shortage areas to increase access to care for Medi-Cal beneficiaries. In October 2019 DHCS provided network analysis data to Physicians for a Healthy California to assist with focusing the loan repayment program efforts on areas with access concerns. Additionally, DHCS will request the health plans conduct an assessment and submit to DHCS a recruitment strategy for areas in the Regional Model not compliant with time and distance standards. The assessment would be due to DHCS three months after the next annual network certification is completed.
California State Auditor's Assessment of Annual Follow-Up Status: Will Not Implement
It remains unclear why DHCS disagrees with this recommendation. DHCS agrees that increasing the number of physicians is beneficial and is implementing the loan repayment program we discuss in the report. Given the extent of the problems we identified, the impact of children not receiving preventive services, and DHCS' inability to improve utilization rates for these services above 50 percent for the past five years, DHCS should pursue multiple approaches to fixing these problems, rather than limiting itself to a single approach.
1-Year Agency Response
DHCS continues to disagree with the recommendation. DHCS does agree increasing the number of physicians who practice in California is beneficial for all health care delivery systems; however, such assessment is not in the purview of DHCS. Other departments such as the Office of Statewide Health Planning and Development are responsible for workforce planning within California. However, DHCS has been actively involved in implementing a physician and dental provider loan repayment program using Proposition 56 funds as authorized and approved in the Budget Act of 2018. These loan repayments will be targeted specifically at newly-practicing providers that agree to see a specific percentage of Medi-Cal patients in their practice (at least 30 percent) and maintain that commitment for at least five years. These loans will be open to both pediatric and adult providers and additional criteria will include providers that are practicing in high-need specialty areas such as child psychiatry or practicing in a medically underserved area.
- Response Date: March 2020
California State Auditor's Assessment of 1-Year Status: Will Not Implement
It remains unclear why DHCS disagrees with this recommendation. It agrees that increasing the number of physicians is beneficial and is implementing the loan repayment program we discuss in the report. Given the extent of the problems we identified, the impact of children not receiving preventive services, and DHCS' inability to improve utilization rates for these services above 50 percent for the past five years, DHCS should pursue multiple approaches to fixing these problems, rather than limiting itself to a single approach.
6-Month Agency Response
DHCS continues to disagree with the recommendation. DHCS does agree increasing the number of physicians who practice in California is beneficial for all health care delivery systems; however, such assessment is not in the purview of DHCS. However, DHCS has been actively involved in implementing a physician and dental provider loan repayment program using Proposition 56 funds as authorized and approved in the Budget Act of 2018. These loan repayments will be targeted specifically at newly practicing providers that agree to see a specific percentage of Medi-Cal patients in their practice (at least 30 percent) and maintain that commitment for at least five years. These loans will be open to both pediatric and adult providers and additional criteria will include providers that are practicing in high-need specialty areas such as child psychiatry or practicing in a medically underserved area.
- Response Date: September 2019
California State Auditor's Assessment of 6-Month Status: Will Not Implement
It remains unclear why DHCS disagrees with this recommendation. It agrees that increasing the number of physicians is beneficial and is implementing the loan repayment program we discuss in the report. Given the extent of the problems we identified in the report, the impact of children not receiving preventive services, and DHCS' inability to improve utilization rates for these services above 50 percent for the past five years, DHCS should pursue multiple approaches to fixing these problems, rather than limiting itself to a single approach.
60-Day Agency Response
DHCS continues to disagree with the recommendation. DHCS does agree increasing the number of physicians who practice in California is beneficial for all health care delivery systems; however, such assessment is not in the purview of DHCS. However, DHCS has been actively involved in implementing a physician and dental provider loan repayment program using Proposition 56 funds as authorized and approved in the Budget Act of 2018. These loan repayments will be targeted specifically at newly-practicing providers that agree to see a specific percentage of Medi-Cal patients in their practice (at least 30 percent) and maintain that commitment for at least five years. These loans will be open to both pediatric and adult providers and additional criteria will include providers that are practicing in high-need specialty areas such as child psychiatry or practicing in a medically underserved area.
- Response Date: May 2019
California State Auditor's Assessment of 60-Day Status: Will Not Implement
It remains unclear why DHCS disagrees with the recommendation. The report acknowledged DHCS' loan repayment program on page 25, however, given the extent of the access problems we identified, the importance of children receiving preventive services, and DHCS' inability to improve the utilization rate for these services, DHCS should adopt more than a single approach, and it should specifically target providers who see children in areas where they are needed most, as stated in the recommendation.
Recommendation #7 To: Health Care Services, Department of
To ensure that children in Medi-Cal have access to all of the preventive services for which they are eligible, DHCS should modify by May 2019 its contracts to make it clear to plans and providers that they are required to provide services according to Bright Futures.
Annual Follow-Up Agency Response From October 2021
DHCS submitted contract updates to CMS on December 30, 2020. DHCS is working on obtaining signatures from MCPs to submit to CMS. The revised language focused on the importance of providing preventive care services according to Bright Futures schedules. Language was added to specifically include the periodicity timeline/schedule established by AAP Bright Futures. Additional contract language was added to clarify requirements for medically necessary services.
- Completion Date: December 2020
California State Auditor's Assessment of Annual Follow-Up Status: Fully Implemented
Annual Follow-Up Agency Response From November 2020
As previously reported, DHCS has drafted contract language which addresses EPSDT. DHCS agrees to provide confirmation to CSA in the next update to confirm the Managed Care Plan (MCP) contract has been submitted to CMS with updates to address EPSDT. The target date for submission is December 2020.
- Estimated Completion Date: December 2020
California State Auditor's Assessment of Annual Follow-Up Status: Partially Implemented
We are continuing to assess this recommendation as partially implemented, given the steps taken by DHCS as reported in its six-month response. We will review the updated contract language when DHCS has finalized it.
1-Year Agency Response
DHCS has drafted contract language which addresses EPSDT. This language will be submitted to CMS by the end of 2020.
- Estimated Completion Date: December 2020
- Response Date: March 2020
California State Auditor's Assessment of 1-Year Status: Partially Implemented
We are continuing to assess this recommendation as partially implemented, given the steps taken by DHCS as reported in its six-month response. We will review the updated contract language when DHCS has finalized it.
6-Month Agency Response
DHCS released an updated EPSDT APL with enhanced language regarding Bright Futures for MCP, stakeholder, and advocate feedback. DHCS has reviewed all stakeholder feedback and made appropriate changes to the APL. The APL was published in August 2019 and has been posted under the following link: https://www.dhcs.ca.gov/formsandpubs/Pages/AllPlanLetters.aspx
- Completion Date: August 2019
- Response Date: September 2019
California State Auditor's Assessment of 6-Month Status: Partially Implemented
Although DHCS has released its All-Plan Letter (APL), it has not updated the contracts to eliminate the unclear language in the contracts that we discuss on page 29 of our report. DHCS informed us that it intends to update the contracts in November 2019.
- Auditee did not address all aspects of the recommendation
60-Day Agency Response
DHCS released an updated EPSDT APL with enhanced language regarding Bright Futures for MCP, stakeholder, and advocate feedback. DHCS is currently incorporating feedback and anticipates publishing the APL no later than June 1, 2019.
- Estimated Completion Date: June 2019
- Response Date: May 2019
California State Auditor's Assessment of 60-Day Status: Pending
We look forward to reviewing the updated all-plan letter with DHCS' 6-month response.
Recommendation #8 To: Health Care Services, Department of
To ensure that eligible children and their families know about all the preventive services they are entitled to through Medi-Cal, DHCS should include by May 2019 clearer and more comprehensive information about those services in its written materials and by September 2019 ensure annual follow-up with any children and their families who have not used those services.
Annual Follow-Up Agency Response From September 2022
There is no agency response for this update. Government Code section 8546.1(d) authorizes the California State Auditor to conduct follow-up audit work on statutorily mandated or legislatively required financial and performance audits. Our office followed up on this March 2019 audit to assess DHCS's status regarding implementation of the eight outstanding recommendations from this report. Below is our assessment of the status of this recommendation based on work we performed during the follow-up audit. All future updates for this recommendation will be posted under the follow-up audit (2022-502).
- Estimated Completion Date: 3/31/2023
California State Auditor's Assessment of Annual Follow-Up Status: Partially Implemented
Although DHCS hired a contractor to develop written materials about children's preventive services—such as brochures, mailing notices, and content that it can post on its website and social media pages—DHCS chose not to publish the materials because they no longer align with DHCS's new communication strategy for children in Medi-Cal. DHCS stated that it will continue to work with key stakeholders to develop new materials and, to the extent feasible, will leverage portions of the original materials that are still applicable. DHCS hopes to make available the new materials by March 2023.
Annual Follow-Up Agency Response From October 2021
DHCS worked with the Center for Health Literacy (CHL) to make extensive edits to the 2022 Evidence of Coverage - Member Handbook to incorporate more robust language regarding the EPSDT benefit. The Member Handbook describes the EPSDT benefit as designed to assure that children receive early detection and care, so that health problems are averted or diagnosed and treated as early as possible. EPSDT was expanded throughout the Member Handbook to various sections including Covered Services, Behavioral Health Treatment, Child and Youth Well Care and the Words to Know definition section. In addition a text box specific to EPSDT was also added to the Member Handbook to emphasize the importance of EPSDT as a medical necessary service. The Member Handbook also describes Covered Services as free.
Also, as part of the Preventive Care Outreach project, DHCS worked with the CHL to review and assess current preventive care outreach materials, as well as interview stakeholders and survey MCPs on current outreach efforts. Using the results of this analysis, CHL created new key messaging and outreach materials including an outreach letter, brochure, website content and social media campaigns all focused on encouraging accessing preventive services including EPSDT. These materials were tested with a sampling of beneficiaries in five languages. The work with CHL concluded on June 30, 2021 and DHCS was provided with the final materials and templates. DHCS is working on next steps for both DHCS and the MCPs to begin using the newly developed outreach materials which would include a letter that reminds beneficiaries about the availability of preventive care services, including blood lead screening.
- Completion Date: August 2021
California State Auditor's Assessment of Annual Follow-Up Status: Partially Implemented
Full implementation of this recommendation requires DHCS to provide information about the benefits of preventive health care and that those services are free to eligible individuals and are available upon request, including information about the benefits of preventive health care and the costs of those services. It will also require targeted reminders specifically to families of children who have not used preventive services in the past year. These are not steps DHCS has yet taken.
- Auditee did not substantiate its claim of full implementation
Annual Follow-Up Agency Response From November 2020
DHCS disagrees regarding the updated Member Handbook language not being adequate, but will commit to reviewing the language and making any necessary updates in the upcoming 2021 Member Handbook template if additional language is determined to be needed.
DHCS has continued implementation of Phase 1 of the Preventive Care Outreach project, and launched the phase of the outreach requiring MCPs to perform targeted outreach via an outbound call campaign. Outreach messaging must reflect notifying beneficiaries of preventive care services not received or not received for an extended period. Due to the ongoing impacts of the COVID 19 pandemic on primary care providers, DHCS has extended the timeframe for calls to be completed as well as allowed plans to use alternate and/or a combination of modalities to perform the required outreach. Outreach campaigns targeting children under age six are expected to be completed no later than June 2021.
Phase 2 of the Preventive Care Outreach project involves researching current preventive care materials and engaging stakeholders, beneficiaries, and health plans to provide feedback on existing materials and outreach efforts. New materials will be created and distributed based on the outcomes of the research. Due to the COVID-19 pandemic, Phase 2 was delayed; however, stakeholder and advocate engagement is scheduled to begin in September 2020. Phase 2 is expected to be completed by June 30, 2021.
- Estimated Completion Date: June 2021
California State Auditor's Assessment of Annual Follow-Up Status: Pending
Full implementation of this recommendation will require DHCS to provide information about the benefits of preventive health care and that those services are free to eligible individuals and are available upon request, including information about the benefits of preventive health care and the costs of those services, in addition to ensuring annual follow-up with children and their families who have not used those services.
1-Year Agency Response
The finalized member handbook updates, with feedback that DHCS received, was provided to plans on July 19, 2019. All approvals by DHCS were completed by September 3, 2019. Currently, all plans are mailing the member handbook update with the revised preventive services language.
The Preventive Care Outreach project will be divided into two phases:
- Phase 1 of the Preventive Care Outreach project directs DHCS to use targeted outreach (via mail and a call campaign) to inform beneficiaries under 21 with full scope Medi-Cal eligibility about the EPSDT services available and how to access services.
On October 1, 2019, DHCS provided a draft outreach notice to plans and other stakeholders for feedback. The extensive stakeholder engagement process included written feedback, a follow-up call with key advocate groups, and the sharing of the notice with incorporated feedback. DHCS will begin mailing the notice on February 28, 2020, to approximately five million Medi-Cal beneficiaries under the age of 21.
Call campaigns, approved by DHCS, will be conducted by the MCPs to beneficiaries under the age of 21. The call campaigns will include notifying beneficiaries of preventive care services they have not received or have not received for an extended period of time.
- Phase 2 of the Preventive Care Outreach project will involve DHCS contracting with an independent entity, Maximus, to conduct surveys of beneficiaries, design outreach materials, and engage with stakeholders in order to determine the best outreach process moving forward. Phase 2 is expected to be completed by December 31, 2020.
- Estimated Completion Date: December 2020
- Response Date: March 2020
California State Auditor's Assessment of 1-Year Status: Pending
The finalized member handbook template that DHCS provided does not address all of the concerns we raise on page 30 of our report. Federal law requires DHCS to provide information about the benefits of preventive health care and that those services are free to eligible individuals and are available upon request. However, the updated handbook continues to include information that is incomplete, such as insufficient information about the benefits of preventive health care and the costs of those services.
6-Month Agency Response
DHCS finalized the language regarding the EPSDT benefit that will be used in the MCP Member Handbook/EOC. The language includes more comprehensive information about beneficiary entitlements under the EPSDT benefit. DHCS provided out to Plans on July 1, 2019, to be used as an errata in their current 2019 Member Handbook. Additional feedback was received by the Plans after it was provided and therefore DHCS is currently making updates. Plans will be expected to have their Plan specific errata approved by DHCS two weeks from the time that the final version of the errata is provided. Plans will be expected to begin mailing the errata with their Member Handbooks immediately after DHCS approval.
DHCS is working internally on the targeted outreach campaign to inform beneficiaries about the availability of the AAP/Bright Futures services under Medi-Cal and how to access them. This outreach will include a process to specifically follow-up with children and their families who have not used preventive services over the course of a year. A timeline for stakeholder engagement is forthcoming.
- Estimated Completion Date: December 2020
- Response Date: September 2019
California State Auditor's Assessment of 6-Month Status: Pending
60-Day Agency Response
DHCS has shared and collected feedback from MCPs, stakeholders, and advocates on draft language regarding the EPSDT benefit that will be used in the MCP Member Handbook/EOC. The language includes more comprehensive information about beneficiary entitlements under the EPSDT benefit. DHCS is on track to finalize the EOC which will include the updated EPSDT language by July 1, 2019.
DHCS is working internally on the targeted outreach campaign to inform beneficiaries about the availability of the American Academy of Pediatrics (AAP)/Bright Futures services under Medi-Cal and how to access them. Stakeholder engagement is forthcoming.
- Estimated Completion Date: December 31, 2020
- Response Date: May 2019
California State Auditor's Assessment of 60-Day Status: Pending
We look forward to reviewing clearer and more comprehensive language about the preventive services children and their families are entitled to in DHCS' updated member handbook and Evidence of Coverage in its 6-month response. We expect DHCS' outreach campaign to include a procedure to specifically follow-up with children and their families who have not used preventive services over the course of a year.
Recommendation #9 To: Health Care Services, Department of
To improve access and utilization rates, DHCS should establish by March 2020 performance measures that cover Bright Futures services through well-child visits for all age groups, and require plans to track and report the utilization rates on those measures.
Annual Follow-Up Agency Response From October 2021
As described above, NCQA has formally amended the well-child measures: "Child and Adolescent Well-Care Visits" measure amended the existing "Well Child Visits in the 3rd-6th Years of Life (W34)," adding new four new age groups: 3-6, 7 11, 12-18, and 19-21 years old. The existing Well-Child Visits measure for the first 15 months of life was replaced with a revised metric, to include services in the first 30 months of life. The rates for the new measure will have two age groups: children who turn 15- or 30-months old during the measure year. Because the well-child metrics are part of DHCS' Managed Care Accountability Set (MCAS), DHCS is in full compliance with CSA's recommendation to track and report the utilization rates on those measures.
- Completion Date: September 2021
California State Auditor's Assessment of Annual Follow-Up Status: Fully Implemented
Annual Follow-Up Agency Response From November 2020
DHCS continues to work with stakeholders towards the PSR. DHCS plans to issue the first version in December 2020 and the second version in February 2021. The first will add program wide data, the second will add plan specific data. Once the PSR is completed, DHCS will instruct the MCPs, using an APL, to use the PSR findings along with plan information, including the MCP's utilization management program, to identify and address barriers to usage.
DHCS will use the PSR as a monitoring and reporting tool to assess appropriate utilization of children's preventative services in Medi-Cal. The PSR will include two revised National Committee for Quality Assurance Well-Child measures being adopted into the formal Managed Care Accountability Set and will be reported by the MCPs starting with Reporting Year 2021.
The new "Child and Adolescent Well-Care Visits" measure amends the existing "Well Child Visits in the 3rd-6th Years of Life (W34)," adding new four new age groups: 3-6, 7 11, 12-18, and 19-21 years old.
The existing Will-Child Visits measure for the first 15 months of life will be replaced with a revised metric, to include services in the first 30 months of life. The rates for the new measure will have two age groups: children who turn 15- or 30-months old during the measure year.
The revised measures will allow DHCS to improve the monitoring of MCPs' provision of well-child visits from birth through age 21 and will fill in existing gaps in capturing information using the prior Well-Child Visit measures. Additional measures are planned for inclusion in the PSR capturing other preventative services recommended by the Bright Futures Periodicity Schedule. DHCS will use the PSR to identify regional, demographic, and other factors potentially causing disparities in the rates. Findings from the PSR will inform DHCS' actions with the MCPs to drive targeted interventions and improvement in the provision of preventive services for children in Medi-Cal.
- Estimated Completion Date: February 2021
California State Auditor's Assessment of Annual Follow-Up Status: Pending
Full implementation of this recommendation will require DHCS to establish performance measures that cover Bright Futures services through well-child visits for all age groups, and to require plans to track and report the utilization rates on those measures.
1-Year Agency Response
DHCS released the draft proposed measures for the 2020 PSR for public comment on January 17, 2020. The public comment period ended on February 3, 2020. DHCS will review the comments received, finalize the performance measures for the report with the EQRO, and continue moving forward with production of the report.
- Estimated Completion Date: December 2020
- Response Date: March 2020
California State Auditor's Assessment of 1-Year Status: Pending
6-Month Agency Response
DHCS implemented the requirement that MCPs report annually on the applicable CMS adult and child CSMs beginning with the current measurement year (2019). DHCS has established the minimum benchmark as the 50th percentile of Medicaid plans nationally where national performance information is available. Many CMS child CSMs align with AAP Bright Futures.
DHCS implemented the VBP Program which provides MCPs with an incentive payment for the provision of specified services starting July 1, 2019, including an enhanced incentive amount when those services are provided to individuals who are homeless, have serious mental illness, or have substance use disorders. Metrics in the VBP Program that align with AAP Bright Futures include well-child visits in the first 15 months and third through sixth years of life, childhood vaccines for two-year-olds, blood lead screening, and dental fluoride varnish. The VBP Program is located here: https://www.dhcs.ca.gov/provgovpart/Pages/VBP_Measures_19.aspx
DHCS is working on implementing the first annual PSR, and expects to complete it in 2020. DHCS is instructing EQRO to utilize encounter data to determine the rates of provision of appropriate preventive services in accordance with AAP Bright Futures, including frequency of well-visits occurring at the recommended ages/intervals and healthcare visits. Currently the EQRO is evaluating the AAP Bright Futures recommendations to determine the measures that are possible to calculate from encounter data. DHCS plans to evaluate alternative data sources for future iterations of the annual report to expand the measures that can be included.
- Estimated Completion Date: 2020
- Response Date: September 2019
California State Auditor's Assessment of 6-Month Status: Pending
This recommendation specifically includes the establishment of performance measures that cover well-child visits for all age groups. DHCS's response indicates that it has begun requiring reporting from plans on certain core set measures, but that it has not yet implemented performance measures for well-child visits for all age groups. We look forward to reviewing its implementation of its reporting requirements in the context of the performance measures for well-child visits for all age groups.
60-Day Agency Response
DHCS has announced that MCPs will report on applicable CMS adult and child core set measures for reporting year 2020 (measurement year 2019) and that MCPs will be required to meet the minimum benchmark of the 50th percentile (up from the 25th percentile) of Medicaid plans nationally where that national performance information is available. DHCS also announced that failure to meet this minimum performance level will lead to immediate sanctions and MCPs may also be placed under a CAP.
Additionally, DHCS has released proposed metrics for the Governor's proposed 2019-20 budget regarding Value Based Payments for public comment. The proposal includes metrics for early childhood development including those related to completion of well child visits, immunizations, and other preventive services such as lead screenings and dental fluoride varnish application.
These metrics are in alignment with AAP/Bright Futures recommended preventive services for children. Furthermore, DHCS has begun working with its EQRO to develop a Preventive Services Report which will utilize available data to calculate metrics of appropriate utilization of preventive services for children and adults. DHCS and the EQRO will look to align with existing quality metrics where available and will investigate the development of metrics where appropriate. The report continues to be expected to be issued in 2020.
- Estimated Completion Date: December 2020
- Response Date: May 2019
California State Auditor's Assessment of 60-Day Status: Pending
DHCS did not provide evidence that it will adopt performance measures that cover Bright Futures services though well-child visits for children of all age groups in its response, or in response to a specific follow-up request. We will look for evidence that it intends to implement this recommendation in DHCS' 6-month response.
Recommendation #10 To: Health Care Services, Department of
To ensure that health plans and providers are adequately delivering children's preventive services, DHCS should implement by September 2019 audit procedures through its annual medical audits that address the delivery of EPSDT services to all eligible children for all plans annually.
1-Year Agency Response
Please see attached workpapers for the 2019 audits of Kaiser, San Mateo, and Community Health Group. The areas in the workpapers that relate to the delivery of EPSDT services are highlighted in yellow.
- Completion Date: July 2019
- Response Date: March 2020
California State Auditor's Assessment of 1-Year Status: Fully Implemented
DHCS demonstrated implementation of the new audit procedures in its recently completed audit workpapers.
6-Month Agency Response
Updated audit procedures have been included in our audit guide and communicated to staff. Implementation will begin immediately for managed care audits.
- Completion Date: July 2019
- Response Date: September 2019
California State Auditor's Assessment of 6-Month Status: Partially Implemented
DHCS' updated audit procedures address the delivery of EPSDT services, but it has not yet demonstrated that it has implemented these procedures through conducting annual medical audits using these new procedures. We look forward to reviewing DHCS' one-year response to learn about the results of its annual medical audits showing implementation of these new procedures.
- Auditee did not substantiate its claim of full implementation
60-Day Agency Response
DHCS is collaborating internally on various methods to monitor plan processes to detect underutilization of children's preventive services and their merits and drawbacks, feasibility given existing criteria, and their anticipated effectiveness. DHCS will develop and incorporate the optimal method into draft audit procedures, pilot test the procedures during a live audit, and refine as needed before finalizing implementation for all audits.
- Estimated Completion Date: September 2019
- Response Date: May 2019
California State Auditor's Assessment of 60-Day Status: Pending
We look forward to reviewing the updated audit procedures with DHCS' 6-month response.
Recommendation #11 To: Health Care Services, Department of
To ensure that plans address underutilization of children's preventive services, DHCS should require plans by September 2019 to use their utilization management programs to identify barriers to usage specifically for these services and hold the plans accountable to address the barriers they identify.
Annual Follow-Up Agency Response From September 2022
There is no agency response for this update. Government Code section 8546.1(d) authorizes the California State Auditor to conduct follow-up audit work on statutorily mandated or legislatively required financial and performance audits. Our office followed up on this March 2019 audit to assess DHCS's status regarding implementation of the eight outstanding recommendations from this report. Below is our assessment of the status of this recommendation based on work we performed during the follow-up audit. All future updates for this recommendation will be posted under the follow-up audit (2022-502).
- Estimated Completion Date: 7/1/2023
California State Auditor's Assessment of Annual Follow-Up Status: Partially Implemented
DHCS has not required health plans to identify barriers to usage of children's preventive services and develop strategies to address those barriers as we recommended. DHCS plans to fully implement this recommendation by July 2023.
Annual Follow-Up Agency Response From October 2021
On September 29, 2020, DHCS issued APL 20-016: Blood Lead Screening of Young Children. This APL informs MCPs of their updated Blood Lead Screening requirements as part of the revisions made in the Welfare and Institutions Code (W&I) by AB 2276. On November 3, 2020, DHCS issued a revised version of APL 20-016 which included additional clarifications to the requirements. To ensure MCP compliance with the new requirements in W&I that were incorporated as Department's new policy by way of APL 20-016, DHCS reviewed managed care plan policies and procedures which outlined the plans' updated approach in the provision and reporting of blood lead screening as specified in the new legislation. In February 2021, DHCS published an Addendum to the PSR, which focused on reporting and analysis of blood lead screening across California for children in Medi-Cal managed care. The PSR Addendum provided blood lead screening rates calculated in accordance with California Title 17 requirements, as well as following the national Medicaid Healthcare Effectiveness Data and Information Set (HEDIS) technical specifications by MCP. Data from the PSR Addendum was provided to each MCP to inform their improvement efforts in Basic Life Support. This same process will be repeated annually with the publication of the PSR.
- Completion Date: August 2021
California State Auditor's Assessment of Annual Follow-Up Status: Pending
DHCS' response does not address this recommendation. As we state in the recommendation and in our previous assessments for this recommendation, full implementation of this recommendation will require DHCS to provide documentation of a requirement for plans to identify barriers to usage specifically for preventive services. We also will look for documentation of DHCS' mechanism for holding plans accountable to address the barriers they identify.
- Auditee did not substantiate its claim of full implementation
- Auditee did not address all aspects of the recommendation
Annual Follow-Up Agency Response From November 2020
DHCS continues to work with stakeholders towards the PSR. The first version is on track to be issued in December 2020 and will include program wide data. The second version, which is on track to be issued in February 2021, will include plan specific information. Once the PSR is completed, DHCS will instruct the MCPs to use the PSR findings in conjunction with plan information, including the MCP's utilization management program, to identify and address barriers to usage. The instruction will be issued in the form of an APL.
- Estimated Completion Date: February 2021
California State Auditor's Assessment of Annual Follow-Up Status: Pending
1-Year Agency Response
DHCS continues to work with stakeholders towards the PSR which is on track to be issued in 2020. Once the report is completed, DHCS will instruct the MCPs to use the PSR findings in conjunction with plan information, including the MCP's utilization management program, to identify and address barriers to usage. The instruction will be issued in the form of an APL.
- Estimated Completion Date: December 2020
- Response Date: March 2020
California State Auditor's Assessment of 1-Year Status: Pending
6-Month Agency Response
DHCS continues to work towards the PSR which will be issued in 2020. As part of the preparation for the PSR, DHCS is in the process of engaging stakeholders to comment on aspects, metrics, and the content of the report. Once the report is completed, DHCS will instruct the MCPs to use the PSR findings in conjunction with plan information, including the MCP's utilization management program, to identify and address barriers to usage.
- Estimated Completion Date: December 2020
- Response Date: September 2019
California State Auditor's Assessment of 6-Month Status: Pending
We look forward to reviewing documentation in the form of all-plan letters, contract language, or other enforceable notice that DHCS is requiring plans to identify barriers to usage specifically for preventive services. We also will look for documentation of DHCS' mechanism for holding plans accountable to address the barriers they identify.
60-Day Agency Response
DHCS has initiated changes with its EQRO to develop a Preventive Services Report which will utilize available data to calculate metrics of appropriate utilization of preventive services for children and adults. DHCS and the EQRO will look to align with existing quality metrics where available and will investigate the development of metrics where appropriate. The report is expected to be issued in 2020.
- Estimated Completion Date: December 2020
- Response Date: May 2019
California State Auditor's Assessment of 60-Day Status: Pending
DHCS' response does not appear to include a requirement for plans to use their utilization management programs to identify barriers to usage, or to hold the plans accountable to address those barriers, but we will review the report it is initiating and the alignment and development of its metrics to determine the extent to which they implement this recommendation.
Recommendation #12 To: Health Care Services, Department of
To better ensure the accuracy of its data and ensure that California receives all available federal Medicaid funding, DHCS should require its EQRO to perform its encounter data validation studies annually using the most recent set of data available, and it should implement recommendations from its EQRO studies.
Annual Follow-Up Agency Response From September 2022
There is no agency response for this update. Government Code section 8546.1(d) authorizes the California State Auditor to conduct follow-up audit work on statutorily mandated or legislatively required financial and performance audits. Our office followed up on this March 2019 audit to assess DHCS's status regarding implementation of the eight outstanding recommendations from this report. Below is our assessment of the status of this recommendation based on work we performed during the follow-up audit. All future updates for this recommendation will be posted under the follow-up audit (2022-502).
- Estimated Completion Date: 1/1/2023
California State Auditor's Assessment of Annual Follow-Up Status: Partially Implemented
DHCS suspended its FY 2019-20 and FY 2020-21 external data validation studies because of the public health emergency. DHCS stated that the next encounter data validation study will conclude in January 2023.
Annual Follow-Up Agency Response From October 2021
In July 2021, DHCS resumed annual EDV activities beginning in State Fiscal Year (SFY) 2021-2022 which will include normal medical record procurement processes. DHCS' contracted EQRO, Health Services Advisory Group, Inc. (HSAG), is hosting a webinar in November 2021 to go over the EDV requirements and provide general updates for the project. HSAG will send an email to all MCP EDV contacts once the date of the webinar has been finalized.
In lieu of the SFY 2020-2021 EDV study, DHCS and HSAG developed an administrative data analysis using encounter, provider, and eligibility data to measure encounter data quality. This study is known as the SFY 2020-2021 Encounter Data Administrative Profile and is currently in progress and will coincide with the resumption of the SFY 2021-2022 EDV activities.
DHCS released APL 20-004 to communicate the suspension of EDV during the Public Health Emergency and has revised the APL to communicate the resumption of the EDV for SFY 2021 2022.
- Completion Date: July 2021
California State Auditor's Assessment of Annual Follow-Up Status: Partially Implemented
As stated in previous assessments, DHCS will need to demonstrate that it has implemented recommendations from its EQRO studies to fully implement this recommendation.
- Auditee did not address all aspects of the recommendation
Annual Follow-Up Agency Response From November 2020
DHCS continues to conduct the EDV study on an annual basis and to review and make decisions on whether or not to implement the recommendations made by the EQRO. Due to the COVID-19 pandemic, DHCS paused the 2020-21 EDV activities to reduce non-critical administrative burden on providers and anticipates a return to normal operation in early 2021 pending the state of the COVID-19 pandemic. DHCS will work with the EQRO to determine the best course of action to reactivate EDV activities.
- Estimated Completion Date: September 2021
California State Auditor's Assessment of Annual Follow-Up Status: Pending
1-Year Agency Response
DHCS has contractual authority to require its EQRO to complete an EDV study on an annual basis and has done so since State Fiscal Year 2017-2018. DHCS utilizes results from the EDV studies as one of many mechanisms to monitor and improve encounter data completeness and accuracy. In addition, DHCS reviews the recommendations made by the EQRO which are included in the annual EDV and makes a decision on whether or not to implement.
- Estimated Completion Date: September 2020
- Response Date: March 2020
California State Auditor's Assessment of 1-Year Status: Partially Implemented
DHCS' updated EQRO contract incorporates the requirement to conduct the encounter data validation study for fiscal year 2019-20. DHCS will need to continue exercising this option annually and demonstrate that it is implementing the recommendations from these studies.
6-Month Agency Response
DHCS is currently evaluating the most recent recommendations provided by its EQRO in the 2017-18 EDV Study that was delivered on March 13, 2019. As recommended, DHCS is evaluating ways to improve study indicators by establishing EDV minimum performance thresholds which will be published in a future version of the Quality Measures for Encounter Data document—an extension of APL 14-020. DHCS is also in the process of investigating whether all diagnosis data in the encounter data is present in the DHCS data warehouse as recommended. Lastly, DHCS is developing contract language that will require MCPs to conduct regular audits of encounter data reported by their subcontractors and network providers.
- Estimated Completion Date: December 31, 2019
- Response Date: September 2019
California State Auditor's Assessment of 6-Month Status: Pending
Implementation of this recommendation will require a change to DHCS' contract with the EQRO and demonstration of a method to ensure that DHCS implements recommendations from the EQRO studies. DHCS did not provide evidence of either, although its response indicates that it intends to implement this recommendation.
60-Day Agency Response
DHCS has expanded its encounter data monitoring efforts in the completeness and accuracy categories through an Encounter Data Validation Study. This study is currently being conducted on an annual basis and brings DHCS into full compliance with new federal requirements. DHCS received the 2017-18 Encounter Data Validation Study in March 2019 and it will be published in May 2019. DHCS' EQRO has already initiated and begun collecting data for the next 2018-19 Encounter Data Validation Study which will be completed in March 2020.
In April 2019, DHCS released the second round of Encounter Data Stoplight reports which compares the amount of utilization reported through each MCP's Rate Development Template and the amount of encounter data submitted to DHCS. The third round of reports will be released in July 2019.
- Completion Date: March 2019
- Response Date: May 2019
California State Auditor's Assessment of 60-Day Status: Partially Implemented
DHCS provided a schedule indicating the data validation study would be annual and stated they intended to make this part of the contract when they renew it in 2020, but it has not provided evidence that it is implementing the recommendations from its EQRO studies.
- Auditee did not address all aspects of the recommendation
Recommendation #13 To: Health Care Services, Department of
To ensure that plan provider directories are accurate, by September 2019 DHCS should begin using a 95 percent confidence level and not more than a 10 percent margin of error on its statistical sampling tool and should require at least 95 percent accuracy before approving a plan's provider directory. In addition, DHCS should ensure that its staff adhere to its policy to retain all documentation related to its review of provider directories for at least three years.
Annual Follow-Up Agency Response From September 2022
There is no agency response for this update. Government Code section 8546.1(d) authorizes the California State Auditor to conduct follow-up audit work on statutorily mandated or legislatively required financial and performance audits. Our office followed up on this March 2019 audit to assess DHCS's status regarding implementation of the eight outstanding recommendations from this report. Below is our assessment of the status of this recommendation based on work we performed during the follow-up audit. All future updates for this recommendation will be posted under the follow-up audit (2022-502).
- Estimated Completion Date: 9/30/2023
California State Auditor's Assessment of Annual Follow-Up Status: Partially Implemented
DHCS is exploring having its external reviewer verify select health plans' provider directory information using a new approach, which would include a larger sample size. DHCS plans to continue to perform the directory reviews for two of the health plans and is considering increasing its sample size once it transfers the other reviews to the external reviewer. However, DHCS does not have a timeline for when it will transfer the verification process to the external reviewer. Further, DHCS has approved provider directories despite finding significant errors in them.
Annual Follow-Up Agency Response From October 2021
While DHCS had expected to resume the Provider Directory Validation work through the EQRO in 2021, DHCS halted work entailing outbound calls so that providers can focus on the COVID-19 pandemic. DHCS expects to resume the work efforts in the first quarter of 2022. When work efforts resume, the EQRO will use the established process for conducting provider directory validation and will provide quarterly results to DHCS based on outbound calls to Providers that are included in the Provider Directory. MCPs will be required to rectify findings that result from the validation.
- Estimated Completion Date: 01/31/2022
California State Auditor's Assessment of Annual Follow-Up Status: Pending
When DHCS resumes its efforts, we will look to determine whether it is using the confidence level, margin of error, and accuracy rate included in this recommendation.
Annual Follow-Up Agency Response From November 2020
DHCS' EQRO established a process for conducting provider directory validation and will be providing quarterly results to DHCS. Requirements for the provider directory review and validation have been established and DHCS' EQRO began making outreach calls to validate provider information in the first quarter of 2020. However, due to the COVID 19 pandemic, the work through DHCS' EQRO is delayed. DHCS expects to reinstate provider directory validation processes in 2021. As requested, documentation showing the methodology used by the EQRO in the first quarter of 2020 to assist with the provider directory review is included. The same methodology will be used when the provider directory review process by the EQRO is re-instated later in 2021 once timing is determined after the COVID-19 pandemic has concluded.
- Estimated Completion Date: December 2021
California State Auditor's Assessment of Annual Follow-Up Status: Pending
1-Year Agency Response
DHCS' EQRO has established a process for conducting provider directory validation and will be providing quarterly results to DHCS. Results from the Provider Directory review will be retained on a SharePoint by Health Care plan.
- Estimated Completion Date: April 2020
- Response Date: March 2020
California State Auditor's Assessment of 1-Year Status: Pending
DHCS did not provide documentation of its new process or its document retention efforts.
6-Month Agency Response
DHCS' EQRO is establishing a process for conducting provider directory validation and will be providing quarterly results to DHCS. Results from the Provider Directory review will be retained on a SharePoint by Health Care Plan. Initial requirements for the Provider Directory review have been established; the targeted implementation timeframe of January 1, 2020, is currently still anticipated.
- Estimated Completion Date: January 1, 2020
- Response Date: September 2019
California State Auditor's Assessment of 6-Month Status: Pending
60-Day Agency Response
DHCS' EQRO is establishing a process for conducting provider directory validation quarterly. Initial requirements are being discussed; the targeted implementation timeframe of January 1, 2020 is currently still anticipated.
- Estimated Completion Date: January 1, 2020
- Response Date: May 2019
California State Auditor's Assessment of 60-Day Status: Pending
We look forward to reviewing the progress DHCS has made to implement the recommendation to both increase the validation level and ensure staff adhere to its policy to retain documentation related to its provider directory reviews with DHCS' 6-month and 1-year responses.
Recommendation #14 To: Health Care Services, Department of
To mitigate health disparities for children of differing ethnic backgrounds and language needs, DHCS should revise by September 2019 the methodology for its EQRO's health disparity study to enable it to better make demographic comparisons, and it should use the findings to drive targeted interventions within plan service areas. It should publish this study annually.
Annual Follow-Up Agency Response From September 2022
There is no agency response for this update. Government Code section 8546.1(d) authorizes the California State Auditor to conduct follow-up audit work on statutorily mandated or legislatively required financial and performance audits. Our office followed up on this March 2019 audit to assess DHCS's status regarding implementation of the eight outstanding recommendations from this report. Below is our assessment of the status of this recommendation based on work we performed during the follow-up audit. All future updates for this recommendation will be posted under the follow-up audit (2022-502).
- Estimated Completion Date: 1/1/2023
California State Auditor's Assessment of Annual Follow-Up Status: Partially Implemented
DHCS has not revised the methodology for its EQRO's health disparity study to enable it to better make demographic comparisons. DHCS plans to fully implement this recommendation by January 2023.
Annual Follow-Up Agency Response From October 2021
Leveraging data from our health disparities reports, DHCS is currently working on a study to determine potential metrics that experience the highest disparities for our managed care Medi-Cal population not only based on race/ethnicity, age, gender, and language but also by geographical location. These identified metrics will potentially be the focus for a state driven project to improve these disparities. MCP's will need to improve disparities in a specified timeframe and by a predetermined quantifiable amount. Additionally, the health disparities report is undergoing a few methodological updates to allow for better reporting, accuracy, and fluidity of the reports. The reports will continue to be published annually.
- Estimated Completion Date: 01/03/2022
California State Auditor's Assessment of Annual Follow-Up Status: Partially Implemented
Full implementation will require DHCS to show that the study it describes allows for demographic and that its findings are used to drive targeted interventions.
Annual Follow-Up Agency Response From November 2020
PNA submissions have been received and are being reviewed by DHCS. Analysis and reporting of PNAs, including MCP-identified health disparities, will be included in DHCS' Plan Specific Evaluation Report included in DHCS' April 2021 Technical Report as previously reported. DHCS fully intends to continue to publish the Health Disparities Report, based on the annual quality metrics when possible. Due to the COVID-19 pandemic, MCPs were given flexibilities in reporting annual quality metrics for Reporting Year 2020, aligning with flexibilities given by CMS and the National Committee for Quality Assurance. Please see Supplement to APL 19-017 for more information regarding reporting flexibilities, which can be found here: https://www.dhcs.ca.gov/formsandpubs/Documents/MMCDAPLsandPolicyLetters/APL2019/APL19-017QISupp.pdf. The methodologies used in previous reports are not appropriate to apply to the Reporting Year 2020 quality metrics. Therefore, the annual report cannot be produced using the same data source or methodology as previous years.
- Estimated Completion Date: April 2021
California State Auditor's Assessment of Annual Follow-Up Status: Pending
Full implementation of this recommendation will require DHCS to demonstrate that it's methodology for its EQRO's health disparity study enables it to make demographic comparisons, and that it uses findings from the study to drive targeted interventions within plan service areas and that it publishes the study annually.
1-Year Agency Response
DHCS has continued to move forward with the annual Health Disparities Reports, utilizing the improved methodology and identifying opportunities to expand the measures and stratifications included in future iterations of the report. DHCS has also continued to move forward with policy initiatives that will require the MCPs to utilize data from this report for purposes of identifying health disparities. APL "Health Education and Cultural and Linguistic Population Needs Assessment" was published September 30, 2019, (DHCS notes that the GNA was renamed Population Needs Assessment (PNA) to clarify the policy applied to the entire MCP member population as opposed to particular groups, but the substance of the requirement was not impacted by the name change). On November 7, 2019, DHCS conducted a webinar for MCP Health Education Consultants to review the submission requirements and timeframe of the PNA. PNA submissions are due to DHCS June 30, 2020. DHCS informed the MCPs that the health disparities data is required to be utilized for their submission. On December 17, 2019, DHCS informed MCPs the health disparities data from measurement years 2017 and 2018 was available to MCPs by the EQRO. DHCS requires PNA submissions to utilize available data to describe and identify health disparities within the MCP member population. Analysis and reporting of PNAs, including MCP-identified health disparities, will be included in DHCS' Plan Specific Evaluation Report included in DHCS' April 2021 Technical Report.
- Estimated Completion Date: April 2021
- Response Date: March 2020
California State Auditor's Assessment of 1-Year Status: Partially Implemented
DHCS submitted an updated All Plan Letter and documentation of the webinar described in its response. Full implementation of this recommendation will require DHCS to demonstrate that it uses findings from the study to drive targeted interventions within plan service areas and that it publishes the study annually.
6-Month Agency Response
DHCS has continued to move forward with the annual Health Disparities Reports, utilizing the improved methodology and identifying opportunities to expand the measures and stratifications included in future iterations of the report. DHCS has also continued to move forward with policy initiatives that will require the MCPs to utilize data from this report for purposes of identifying health disparities, developing an action plan to address the health disparity, and reporting back to DHCS on the progress and impact of the action plan as part of the Group Needs Assessment (GNA). The second Disparities Report was posted before June. The date for completion has been modified to September 2019 to account for the submission of two additional methodologies which detail the upcoming evolution of the report.
- Completion Date: September 2019
- Response Date: September 2019
California State Auditor's Assessment of 6-Month Status: Partially Implemented
DHCS' revised EQRO methodology now allows for demographic comparisons in ways the previous methodology did not. However, DHCS has not addressed other aspects of this recommendation, specifically demonstrating that it uses the enhanced demographic comparisons from the EQRO to drive targeted interventions within plan service areas.
- Auditee did not address all aspects of the recommendation
60-Day Agency Response
The second health disparities report (measurement year 2016) methodology has been revised to allow for additional metrics and demographic comparisons and will be released in Spring 2019. The EQRO will continue to produce this report on an annual basis and each iteration will continue to evolve as DHCS identifies opportunities to improve methodologies, expand the metrics being analyzed, and drive targeted interventions within MCP service areas.
- Estimated Completion Date: June 2019
- Response Date: May 2019
California State Auditor's Assessment of 60-Day Status: Partially Implemented
We reviewed DHCS' revised EQRO methodology, and it allows for demographic comparisons in ways the previous methodology did not. We look forward to seeing future updates from DHCS in which it demonstrates that it uses the enhanced demographic comparisons from the EQRO to drive targeted interventions within particular service areas.
Recommendation #15 To: Health Care Services, Department of
To ensure that plans are effectively mitigating child health disparities in their service area, DHCS should implement by September 2019 a policy to require the plans to take action on the most significant findings cited in their group needs assessment reports, and to regularly follow up with the plans to ensure they have addressed the findings.
1-Year Agency Response
APL "Health Education and Cultural and Linguistic Population Needs Assessment" was published September 30, 2019. DHCS notes that the GNA was renamed PNA to clarify that the policy applied to the entire MCP member population as opposed to particular groups, but the substance of the requirement was not impacted by the name change.
- Completion Date: September 2019
- Response Date: March 2020
California State Auditor's Assessment of 1-Year Status: Fully Implemented
DHCS' All Plan Letter includes a requirement for plans to take action on the most significant findings cited in their group needs assessment reports and specifies that DHCS will follow up with the plans to ensure that they have addressed the findings.
6-Month Agency Response
DHCS has shared the draft GNA APL for public comment and is in the process of incorporating feedback from the public comment period into the final APL, which will be published in September 2019.
- Completion Date: September 2019
- Response Date: September 2019
California State Auditor's Assessment of 6-Month Status: Pending
DHCS' response indicates that its All Plan Letter is still in draft form. We look forward to reviewing it when it is finalized, specifically focusing on whether it includes a required action plan and regular follow-up with the plans to ensure that they have addressed the findings.
- Auditee did not substantiate its claim of full implementation
60-Day Agency Response
DHCS is updating its APL to clarify the requirements and format of the annual MCP submission for the GNA. DHCS will have the EQRO incorporate the available information from the GNA submissions into the corresponding Plan Specific Evaluation Reports and provide recommendations pertaining to the GNAs. DHCS will follow-up with MCPs to ensure they are engaging in efforts to address recommendations.
- Estimated Completion Date: April 2020
- Response Date: May 2019
California State Auditor's Assessment of 60-Day Status: Pending
We look forward to reviewing the updated policy in DHCS' 6-month response.
Recommendation #16 To: Health Care Services, Department of
To help increase utilization rates, DHCS should begin by September 2019 to monitor and identify effective incentive programs at the plan level and share the results with all plans.
Annual Follow-Up Agency Response From September 2022
There is no agency response for this update. Government Code section 8546.1(d) authorizes the California State Auditor to conduct follow-up audit work on statutorily mandated or legislatively required financial and performance audits. Our office followed up on this March 2019 audit to assess DHCS's status regarding implementation of the eight outstanding recommendations from this report. Below is our assessment of the status of this recommendation based on work we performed during the follow-up audit. All future updates for this recommendation will be posted under the follow-up audit (2022-502).
- Estimated Completion Date: 2023
California State Auditor's Assessment of Annual Follow-Up Status: Partially Implemented
DHCS shared some incentive program information with health plans. However, the information it shared lacked sufficient detail about the identified best practices for incentive programs to be useful. DHCS plans to share additional information with the health plans in October 2022 and to launch a new incentive program in 2023.
Annual Follow-Up Agency Response From October 2021
In April 2021, DHCS implemented a Primary Care Incentive Tracking Report with its contracted health plans/managed care organizations (MCOs), focused on members less than 21 years of age. The report solicited information on all provider incentives and other value-based payment (VBP) arrangements MCOs are utilizing to incentivize wellness and preventive care for child and adolescent members and any best practices the MCOs have identified. The report gathered information on HEDIS or other quality metrics used within the payment arrangements or incentives and any member incentives the MCOs have implemented, such as gift cards or other rewards that members earn when they access wellness or preventative care services.
The MCO submissions demonstrated an array of VBP approaches in use from 2018-2019 designed to improve wellness and preventive care with the majority being pay-for-performance type incentives. There was at least one VBP model in place during the reporting period in all 58 California counties. More than half of MCOs reported using child and adolescent wellness and preventive care measures from the Eternal MCAS of quality measures, now known as the MCAS, in their payment arrangements. Seventeen MCOs reported using member incentives for child and adolescent preventative care.
Moving forward, this report will collect information on primary care incentives annually and information will be shared with Medi-Cal health plans through the quarterly Chief Medical Officer meetings and quarterly quality improvement collaborative meetings to disseminate best practices across plans.
- Completion Date: April 2021
California State Auditor's Assessment of Annual Follow-Up Status: Pending
We will review the Primary Care Incentive tracking report and related policies once DHCS provides them and indicates it has begun sharing the information with all plans.
- Auditee did not substantiate its claim of full implementation
- Auditee did not address all aspects of the recommendation
Annual Follow-Up Agency Response From November 2020
Work efforts were interrupted due to the COVID-19 pandemic and related reprioritization of workload. As such, DHCS was unable to finalize the policy and reporting requirements to share with a Medi-Cal MCP workgroup for feedback. Since the COVID 19 pandemic was declared, DHCS' discussions with the workgroup have focused almost exclusively on COVID-19 pandemic-related impacts. The new implementation date for the recommendation is expected to be April 2021.
For next steps, DHCS still intends to share the high-level policy and reporting requirements with a Medi-Cal MCP workgroup for feedback. In addition, implementing the recommendation will require DHCS establish a new ongoing reporting obligation not currently outlined in DHCS' contracts with the plans. Therefore, in order to formally require plans to comply with the new reporting obligation, DHCS will be implementing the recommendation via APL guidance. DHCS will develop, finalize, and release the APL required to implement the recommendation following receipt of the MCP workgroup's feedback.
- Estimated Completion Date: April 2021
California State Auditor's Assessment of Annual Follow-Up Status: Pending
1-Year Agency Response
Work efforts to implement this recommendation commenced in late 2019 and are currently ongoing. To date, DHCS has drafted the internal policy and project plan that will guide work activities necessary for implementing this recommendation and once finalized, DHCS anticipates sharing the high-level policy and reporting requirements with a Medi-Cal MCP workgroup for technical feedback and suggestions.
Implementing this recommendation will require DHCS establish a new ongoing reporting obligation not currently outlined in DHCS' contracts with the plans. Therefore, in order to formally require plans to comply with this new reporting obligation, DHCS will be implementing this recommendation via APL guidance. DHCS will develop, finalize, and release the APL required to implement this recommendation following receipt of the plan workgroup's technical feedback.
- Estimated Completion Date: July 2020
- Response Date: March 2020
California State Auditor's Assessment of 1-Year Status: Pending
6-Month Agency Response
DHCS anticipates efforts in the summer of 2019 to establish a go forward practice to collect and share plan-identified effective incentive programs that are reported to DHCS as contractually required. At the time of the 60-day response, the estimated implementation of September 30, 2019, was indicated assuming work efforts would commence in early summer. Due to significant workload in June and July related to meeting federal rate and claiming-related deadlines, work efforts have been slightly delayed to October 31, 2019.
- Estimated Completion Date: October 31, 2019
- Response Date: September 2019
California State Auditor's Assessment of 6-Month Status: Pending
60-Day Agency Response
DHCS anticipates efforts in the Summer of 2019 to establish a go forward practice to collect and share plan-identified effective incentive programs that are reported to DHCS as contractually required.
- Estimated Completion Date: September 30, 2019
- Response Date: May 2019
California State Auditor's Assessment of 60-Day Status: Pending
We look forward to reviewing DHCS' progress in implementing this recommendation in its 6-month response.
Recommendation #17 To: Health Care Services, Department of
To improve the usefulness of its PDSA process, DHCS should implement by September 2019 a process to share the results of successful strategies with all plans and require plans to share these results with providers who could benefit from them.
1-Year Agency Response
DHCS continues to share promising practices through all the avenues previously discussed. DHCS added additional questions to the annual MCP survey as previously discussed. DHCS shared the results of the survey, including the results of the additional question through the QI Toolkit in September 2019. DHCS notified the MCPs of this addition to the Toolkit via email and instructed the MCPs to share promising practices with their providers as appropriate. DHCS also shared the promising practices with the MCPs through an in-person meeting with the MCP Medical Directors in October 2019. DHCS has identified the QI Toolkit as the best centralized location to maintain records of promising practices and will continue to update the QI Toolkit on an ongoing basis, in addition to sharing promising practices through the other avenues already discussed.
- Completion Date: September 2019
- Response Date: March 2020
California State Auditor's Assessment of 1-Year Status: Fully Implemented
DHCS provided evidence that it compiled promising practices by requiring plans to share them using the QI toolkit. DHCS also demonstrated that it shared promising practices with all managed care plans.
6-Month Agency Response
DHCS continues to share promising practices through all avenues previously discussed, and continues to identify new ways to share promising practices. DHCS conducted the annual Quality Improvement (QI) Survey with the MCPs and incorporated new questions into that survey, requiring the MCPs to provide information on their successful interventions and interventions that they are continuing to spread. DHCS will be compiling the results of the survey to share the information back with all MCPs through a number of forums, including through the QI Toolkit as well as through in-person meetings. DHCS will continue to engage further with MCPs to share promising practices. In the next update, DHCS intends to share the QI Toolkit and agendas from in person meetings.
- Completion Date: September 2019
- Response Date: September 2019
California State Auditor's Assessment of 6-Month Status: Pending
DHCS has begun compiling practices from its PDSA process but has not yet begun sharing those practices with all plans as we recommend. Specifically, it has not yet demonstrated a formal process to share the results of successful strategies with all plans or implemented a requirement that plans share the results of successful strategies with providers who could benefit from them. DHCS' reference to sharing through avenues previously discussed is addressed on page 48 of our report.
- Auditee did not substantiate its claim of full implementation
- Auditee did not address all aspects of the recommendation
60-Day Agency Response
DHCS continues to share promising practices through all avenues previously discussed, and continues to identify new ways to share promising practices. DHCS will engage further with MCPs to share best practices and issue a document summarizing them. DHCS will work with MCPs to identify appropriate best practices to be implemented in their respective geographic areas.
- Estimated Completion Date: December 2019
- Response Date: May 2019
California State Auditor's Assessment of 60-Day Status: Pending
We look forward to reviewing documentation supporting the implementation of this recommendation in DHCS' 6-month response.
Recommendation #18 To: Health Care Services, Department of
To improve its ability to ensure that children are receiving recommended preventive health services, DHCS should create by September 2019 an action plan to annually address the EQRO's recommendations relating to children's preventive services, including recommendations left unaddressed from the previous two years' reports.
Annual Follow-Up Agency Response From September 2022
There is no agency response for this update. Government Code section 8546.1(d) authorizes the California State Auditor to conduct follow-up audit work on statutorily mandated or legislatively required financial and performance audits. Our office followed up on this March 2019 audit to assess DHCS's status regarding implementation of the eight outstanding recommendations from this report. Below is our assessment of the status of this recommendation based on work we performed during the follow-up audit. All future updates for this recommendation will be posted under the follow-up audit (2022-502).
- Estimated Completion Date: 1/1/2023
California State Auditor's Assessment of Annual Follow-Up Status: Partially Implemented
DHCS has not demonstrated that it implemented the EQRO's prior recommendations. DHCS plans to fully implement this recommendation by January 2023.
Annual Follow-Up Agency Response From October 2021
DHCS implemented this recommendation by updating internal operating procedures in the EQRO Contract Management Unit to ensure all of the EQRO recommendations for improvement are understood and information is shared with appropriate DHCS areas responsible for addressing those recommendations.
DHCS will also implement an internal process of regular status checks across all of the areas impacted by the EQRO's recommendations to ensure progress is being taken throughout the year. To that end, DHCS is in the process of drafting explicit responses to EQRO recommendations to address prior year's recommendations which will be published in the 20-21 EQRO Technical Report in April 2022. Please note that DHCS may not agree with some of the EQRO's recommendations, and there are some recommendations that have been implemented or explored as Pilot Studies during 2021, as will be reflected in the April 2022 release of the EQRO Technical Report.
- Completion Date: September 2021
California State Auditor's Assessment of Annual Follow-Up Status: Partially Implemented
DHCS' new documented process includes annually addressing the EQRO's recommendations, and we will review its 2020-21 technical report once DHCS publishes it. We will be looking to verify that DHCS' process leads to it addressing recommendations left unaddressed from prior EQRO reports, including the reports from the two years referenced in our recommendation.
- Auditee did not address all aspects of the recommendation
Annual Follow-Up Agency Response From November 2020
DHCS will continue to require the EQRO to include in the annual Technical Report, an evaluation of each MCP's follow-up on actions in response to the prior years' recommendations. The most recent report, published in July 2020, includes the stated evaluation. See each MCP's "Recommendations" section within the Plan Specific Evaluation Reports, in Volume 2 of the Technical Report, found here: https://www.dhcs.ca.gov/Documents/CA2018-19-EQR-Technical-Report-Vol2.pdf
- Completion Date: July 2020
California State Auditor's Assessment of Annual Follow-Up Status: No Action Taken
DHCS' response does not indicate that it has created an action plan to address the recommendations from its most recent July 2020 report or any recommendations left unaddressed from previous years.
1-Year Agency Response
DHCS has instructed the EQRO to evaluate each MCPs actions in response to the prior two years' worth of EQRO recommendations in the annual technical reports. MCPs have been notified that they will be required to report to the EQRO their actions in response to the recommendations as described. The evaluations are being incorporated into the annual technical report which will be available in April 2020.
- Estimated Completion Date: April 2020
- Response Date: March 2020
California State Auditor's Assessment of 1-Year Status: Pending
6-Month Agency Response
DHCS has instructed the EQRO to evaluate each MCPs actions in response to the prior two years' worth of EQRO recommendations in the annual technical reports. MCPs have been notified that they will be required to report to the EQRO their actions in response to the recommendations as described. Although the plan to incorporate an assessment of MCP's actions to recommendations has been created before September 2019, the report including the evaluations will not be available until April 2020.
- Estimated Completion Date: April 2020
- Response Date: September 2019
California State Auditor's Assessment of 6-Month Status: Pending
60-Day Agency Response
DHCS is developing a process to evaluate recommendations relating to children's preventive services and determine those which MCPs should operationalize through an action plan. These findings will be incorporated into the EQRO's annual technical report which is submitted to CMS in April of each year. DHCS will need approximately eight months to address prior year findings.
- Estimated Completion Date: April 2020
- Response Date: May 2019
California State Auditor's Assessment of 60-Day Status: Pending
We look forward to evaluating DHCS' progress in implementing this recommendation in its 6-month and 1-year responses.
Recommendation #19 To: Health Care Services, Department of
To maximize the benefits of the studies it commissions from its EQRO, DHCS should ensure that by September 2019 the EQRO's annual reports include an assessment of the actions plans have taken to address the EQRO's prior-year recommendations.
Annual Follow-Up Agency Response From November 2020
DHCS will continue to require the EQRO to include in the annual Technical Report, an evaluation of each MCP's follow-up actions in response to the prior years' recommendations. The most recent report, published in July 2020, includes the evaluation. See each MCP's "Recommendations" section within the Plan Specific Evaluation Reports, in Volume 2 of the Technical Report found here: https://www.dhcs.ca.gov/Documents/CA2018-19-EQR-Technical-Report-Vol2.pdf
- Completion Date: July 2020
California State Auditor's Assessment of Annual Follow-Up Status: Fully Implemented
As we recommended, the EQRO report now includes an assessment of MCP's follow-up actions.
1-Year Agency Response
DHCS has instructed the EQRO to evaluate each MCPs actions in response to the prior two years' worth of EQRO recommendations in the annual technical reports. MCPs have been notified that they will be required to report to the EQRO their actions in response to the recommendations as described. The evaluations are being incorporated into the annual technical report which will be available in April 2020.
- Estimated Completion Date: April 2020
- Response Date: March 2020
California State Auditor's Assessment of 1-Year Status: Partially Implemented
DHCS' current contract requires the EQRO to include an assessment of the degree to which each plan has addressed effectively the quality improvement recommendations made by the EQRO during the prior reporting periods' review.
6-Month Agency Response
DHCS has instructed the EQRO to evaluate each MCPs actions in response to the prior two years' worth of EQRO recommendations in the annual technical reports. MCPs have been notified that they will be required to report to the EQRO their actions in response to the recommendations as described. Although instructions have been given to, and are being implemented by, the EQRO before September 2019, the report including the evaluations will not be available until April 2020.
- Estimated Completion Date: April 2020
- Response Date: September 2019
California State Auditor's Assessment of 6-Month Status: Pending
60-Day Agency Response
DHCS is working with the EQRO to clearly incorporate an assessment of actions taken by MCPs to the prior year's recommendations. The assessment will occur for the 2019 recommendations and be incorporated into the technical report that is submitted to CMS in April of 2020.
- Estimated Completion Date: April 2020
- Response Date: May 2019
California State Auditor's Assessment of 60-Day Status: Pending
We look forward to reviewing changes to DHCS' agreement with its EQRO and seeing changes in the technical report in DHCS' 6-month or 1-year response.
All Recommendations in 2018-111
Agency responses received are posted verbatim.