Report 2018-603 Recommendation 3 Responses
Report 2018-603: Department of Health Care Services: It Paid Billions in Questionable Medi-Cal Premiums and Claims Because It Failed to Follow Up on Eligibility Discrepancies (Release Date: October 2018)
Recommendation #3 To: Health Care Services, Department of
To prevent future erroneous payments, Health Care Services should implement procedures by December 31, 2018, to ensure the timely resolution of system discrepancies. These procedures should include Health Care Services regularly following up on recurring, unresolved system discrepancies with the responsible county.
DHCS will resume all previously enacted MEDS alerts monitoring efforts including the MEDS Alert Pilot, in June 2024 when the Continuous Coverage Unwinding Period ends.
- Estimated Completion Date: 06/01/2024
California State Auditor's Assessment of Status: Pending
DHCS does not expect to fully implement this recommendation until June 2024.
Beginning February 1, 2020, DHCS began monitoring the MEDS alerts reports for all 58 counties. DHCS identified six additional counties to incorporate in a second pilot. DHCS planned to initiate the second pilot in April 2020. Due to the COVID-19 public health emergency, efforts are now suspended.
Please refer to the following documents for further information:
- Request for Section 1135 Waiver Flexibilities Related to COVID-19 Emergency
- Medi-Cal Eligibility Division Information Letter No. I20-07
- Request for Federal Waiver to Cover Medi-Cal Recipients and Expand Tele-Health Options
- California Executive Order N-29-20
Otherwise, no changes from the 48 Month update submitted to CSA on August 4, 2022.
- Estimated Completion Date: 03/01/2024
California State Auditor's Assessment of Status: Pending
Per Health Care Services' response, it will not fully implement this recommendation until March 2024.
The estimated implementation date was extended by four months to 3/1/2024, due to an extension of the Federal PHE for COVID-19. No changes from 45-Month Program Update.
- Estimated Completion Date: 3/1/2024
California State Auditor's Assessment of Status: Pending
Per Health Care Services' response, it will not implement this recommendation until March 2024.
The Estimated Implementation Date was extended by four months due to an extension of the Federal PHE for COVID-19. Otherwise, no change from previous response.
Beginning February 1, 2020, DHCS began monitoring the MEDS alerts reports for all 58 counties. DHCS identified six additional counties to incorporate in a second pilot. DHCS planned to initiate the second pilot in April 2020. Due to the COVID-19 PHE, efforts are now suspended.
Please refer to the following documents submitted with 39-Month Update in January 2022 for further information:
- Request for Section 1135 Waiver Flexibilities Related to COVID-19 Emergency (Attachment 5).
- MCED Information Letter No. I20-07 (Attachment 6).
- California Requests Federal Government Waiver to Cover Medi-Cal Recipients and Expand Tele-Health Options (Attachment 7).
- California Executive Order N-29-20 (Attachment 8).
- Estimated Completion Date: 11/1/2023
California State Auditor's Assessment of Status: Pending
Per Health Care Services' response, it will not fully implement this recommendation until November 2023.
DHCS plans to move forward with the implementation plan provided in the previous update upon termination of the federal public health emergency with no modifications to the original plan: Beginning February 1, 2020, DHCS began monitoring the MEDS alerts reports for all 58 counties. DHCS identified six additional counties to incorporate in a second pilot. DHCS planned to initiate the second pilot in April 2020. Due to the COVID-19 public health emergency, efforts are now suspended.
Please refer to the following documents submitted with 39-Month Update in January 2022 for further information:
-Request for Section 1135 Waiver Flexibilities Related to COVID-19 Emergency (Attachment 5).
-MCED Information Letter No. I20-07 (Attachment 6).
-California Requests Federal Government Waiver to Cover Medi-Cal Recipients and Expand Tele-Health Options (Attachment 7).
-California Executive Order N-29-20 (Attachment 8).
- Estimated Completion Date: 07/01/2023
California State Auditor's Assessment of Status: Pending
Per Health Care Services' response, it will not fully implement this recommendation until July 2023.
Response is unchanged from the 36-Month update: Beginning February 1, 2020, DHCS began monitoring the MEDS alerts reports for all 58 counties. DHCS identified six additional counties to incorporate in a second pilot. DHCS planned to initiate the second pilot in April 2020. Due to the COVID-19 public health emergency, efforts are now suspended.
Please refer to the following documents for further information:
- Request for Section 1135 Waiver Flexibilities Related to COVID-19 Emergency
- Medi-Cal Eligibility Division Information Letter No. I20-07
- California Requests Federal Government Waiver to Cover Medi-Cal Recipients and Expand Tele-Health Options
- California Executive Order N-29-20
- Estimated Completion Date: 12/31/2022
California State Auditor's Assessment of Status: Pending
Per Health Care Services' response, it will not fully implement this recommendation until December 2022.
Response is unchanged from 33-Month Update. Beginning February 1, 2020, DHCS began monitoring the MEDS alerts reports for all 58 counties. DHCS identified six additional counties to incorporate in a second pilot. DHCS planned to initiate the second pilot in April 2020. Due to the COVID-19 public health emergency, efforts are now suspended.
Please refer to the following documents for further information:
- Request for Section 1135 Waiver Flexibilities Related to COVID-19 Emergency
- Medi-Cal Eligibility Division Information Letter No. I20-07
- California Requests Federal Government Waiver to Cover Medi-Cal Recipients and Expand Tele-Health Options
- California Executive Order N-29-20
- Estimated Completion Date: 12/31/2022
California State Auditor's Assessment of Status: Pending
Per Health Care Services' response, it will not fully implement this recommendation until December 2022.
Response is unchanged from 30-Month Update. Beginning February 1, 2020, DHCS began monitoring the MEDS alerts reports for all 58 counties. DHCS identified six additional counties to incorporate in a second pilot. DHCS planned to initiate the second pilot in April 2020. Due to the COVID-19 public health emergency, efforts are now suspended.
Please refer to the following documents for further information:
- Rec 3 - MEDIL No. I 20-07 (Attachment 2)
- Rec 3 - Executive Order N-29-20 (Attachment 1)
- Estimated Completion Date: December 31, 2022
California State Auditor's Assessment of Status: Pending
Per the department's response, it will not fully implement this recommendation until December 2022.
Response is unchanged from 27-Month Update. Beginning February 1, 2020, DHCS began monitoring the MEDS alerts reports for all 58 counties. DHCS identified six additional counties to incorporate in a second pilot. DHCS planned to initiate the second pilot in April 2020. Due to the COVID-19 public health emergency, efforts are now suspended.
Please refer to the following documents for further information:
- Request for Section 1135 Waiver Flexibilities Related to COVID-19 Emergency
- Medi-Cal Eligibility Division Information Letter No. I20-07
- California Requests Federal Government Waiver to Cover Medi-Cal Recipients and Expand Tele-Health Options
- California Executive Order N-29-20
- Estimated Completion Date: December 2022
California State Auditor's Assessment of Status: Pending
Per the department's response, it will not fully implement this recommendation until December 2022.
Response is unchanged. Beginning February 1, 2020, DHCS began monitoring the MEDS alerts reports for all 58 counties. DHCS identified six additional counties to incorporate in a second pilot. DHCS planned to initiate the second pilot in April 2020. Due to the COVID-19 pandemic, efforts are now suspended.
Please refer to the attachments below for further information:
- Request for Section 1135 Waiver Flexibilities Related to COVID-19 Emergency
- Medi-Cal Eligibility Division Information Letter No. I20-07
- California Requests Federal Government Waiver to Cover Medi-Cal Recipients and Expand Tele-Health Options
- California Executive Order N-29-20
- Estimated Completion Date: December 2022
California State Auditor's Assessment of Status: Pending
Per the department's response, it will not fully implement this recommendation until December 2022.
Response is unchanged. Beginning February 1, 2020, DHCS began monitoring the MEDS alerts reports for all 58 counties. DHCS identified six additional counties to incorporate in a second pilot. DHCS planned to initiate the second pilot in April 2020. Due to the COVID-19 public health emergency, efforts are now suspended.
Please refer to the attachments below for further information:
- Request for Section 1135 Waiver Flexibilities Related to COVID-19 Emergency
- Medi-Cal Eligibility Division Information Letter No. I20-07
- California Requests Federal Government Waiver to Cover Medi-Cal Recipients and Expand Tele-Health Options
- California Executive Order N-29-20
- Estimated Completion Date: December 2022
California State Auditor's Assessment of Status: Pending
Per the department's response, it will not fully implement this recommendation until December 2022.
Response is unchanged. Beginning February 1, 2020, DHCS began monitoring the MEDS alerts reports for all 58 counties. DHCS identified six additional counties to incorporate in a second pilot. DHCS planned to initiate the second pilot in April 2020. Due to the COVID-19 public health emergency, efforts are now suspended.
Please refer to the attachments below for further information:
- Request for Section 1135 Waiver Flexibilities Related to COVID-19 Emergency
- Medi-Cal Eligibility Division Information Letter No. I20-07
- California Requests Federal Government Waiver to Cover Medi-Cal Recipients and Expand Tele-Health Options
- California Executive Order N-29-20
- Estimated Completion Date: Unknown
California State Auditor's Assessment of Status: Pending
Beginning February 1, 2020, DHCS began monitoring the MEDS alerts reports for all 58 counties. DHCS identified six additional counties to incorporate in a second pilot. DHCS planned to initiate the second pilot in April 2020. Due to the COVID-19 public health emergency, efforts are now suspended.
Please refer to the attachments below for further information:
- Request for Section 1135 Waiver Flexibilities Related to COVID-19 Emergency
- Medi-Cal Eligibility Division Information Letter No. I20-07
- California Requests Federal Government Waiver to Cover Medi-Cal Recipients and Expand Tele-Health Options
- California Executive Order N-29-20
- Estimated Completion Date: Unknown
California State Auditor's Assessment of Status: Pending
Currently, DHCS' pilot targets the five counties that CSA identified as having the highest number of discrepant records (a total of 85%), and one additional county, San Francisco. Since the pilot contains few counties, communication with a smaller group has proven to be successful in identifying factors that contribute to discrepancies between systems, and facilitating effective solutions to increase synchronization. However, beginning February 1, 2020, DHCS will monitor reports of all 58 counties, and begin the process of working with "high/moderate" risk counties, prior to rolling out the pilot statewide.
- Estimated Completion Date: April 2020
California State Auditor's Assessment of Status: Pending
According to Health Care Services' response, implementation of this recommendation is still pending.
DHCS implemented the pilot on June 25, 2019, and submitted substantiating documentation to CSA on August 19, 2019.
- Completion Date: June 2019
California State Auditor's Assessment of Status: Pending
Health Care Services did not provide sufficient evidence for us to substantiate its claim that it had fully implemented the recommendation.
- Auditee did not substantiate its claim of full implementation
In July 2019, DHCS will implement the MEDS alerts pilot project that was originally scheduled for implementation on May 31, 2019.
DHCS delayed the implementation of the MEDS alerts pilot project to ensure that the reports used for this effort:
- Captured the correct alerts.
- Are formatted to ensure readability.
- Have sort/filter functionalities.
- May be used by DHCS to monitor counties' progress, by developing a secondary report that tracks the number of resolved alerts, ongoing (unresolved) alerts, and the number of new alerts on a monthly basis.
A meeting to discuss the pilot process with the counties is scheduled for June 25, 2019
- Estimated Completion Date: July 31, 2019
California State Auditor's Assessment of Status: Partially Implemented
In August 2019 Health Care Services provided evidence that it is in the process of implementing a pilot program that aims to reduce backlogged alerts. However, Health Care Services' pilot program is only being implemented at a selection of counties.
In November 2018, DHCS implemented a quality control process to assist with identifying systems discrepancies. This process includes sending each county a list of individuals in active transitional aid codes that are active in MEDS only. DHCS is monitoring counties' progress in resolving the discrepancies on a regular basis to assess progress in reducing the number of system discrepancies for this population between the state and county systems. In May 2019, DHCS will deploy a second quality control process that specifically focuses on MEDS alerts generated due to a discrepancy in eligibility status between SAWS and MEDS. DHCS will assess progress to evaluate the extent to which the number of alerts are decreasing at a steady, reasonable rate.
- Estimated Completion Date: May 31, 2019
California State Auditor's Assessment of Status: Partially Implemented
As of November 2018, DHCS implemented a quality control process to assist with identifying systems discrepancies. This process includes sending each county a list of individuals in active transitional aid codes that are active in MEDS only. DHCS will monitor counties' progress in resolving the discrepancies on a regular basis to assess progress in reducing the number of system discrepancies for this population between the state and county systems.
In January 2019, DHCS will deploy a second quality control process that specifically focuses on MEDS alerts generated due to a discrepancy in eligibility status between the Statewide Automated Welfare System and MEDS. DHCS will assess progress to evaluate the extent to which the number of alerts are decreasing at a steady, reasonable rate.
- Estimated Completion Date: January 31, 2019
California State Auditor's Assessment of Status: Partially Implemented
All Recommendations in 2018-603
Agency responses received are posted verbatim.