Report 2013-125 All Recommendation Responses

Report 2013-125: California Department of Health Care Services: Weaknesses in Its Medi-Cal Dental Program Limit Children's Access to Dental Care (Release Date: December 2014)

Recommendation #1 To: Health Care Services, Department of

To ensure that child beneficiaries throughout California can reasonably access dental services under Medi-Cal and to increase child beneficiary utilization and provider participation, Health Care Services should take the following steps for the fee-for-service delivery system by May 2015: establish criteria for assessing beneficiary utilization of dental services.

6-Month Agency Response

DHCS consulted with the stakeholder community throughout the month of April 2015 to establish criteria for assessing provider participation and beneficiary utilization. Through this collaborative effort, DHCS developed dental measures that will increase the Medi-Cal Dental Program's monitoring capabilities and assist DHCS to establish mitigation strategies that improve access and utilization of dental care for Medi-Cal beneficiaries. Beneficiary utilization measures established shall inform outreach efforts in Delta Dental's annual beneficiary outreach and education plan, including activities triggered by the benchmark of 41.17% for underserved areas pursuant to the current Delta Dental contract. DHCS will begin reporting on final measures in the fall of 2015.

Completion Date: April 2015
Response Date: July 2015

California State Auditor's Assessment of 6-Month Status: Fully Implemented

Health Care Services provided a document labeled "Policies and Procedures Guide for Beneficiary Utilization Measurements" (guide). This guide identifies the utilization criteria (41.17 percent), five utilization measures (e.g., annual dental visit, use of preventive services, and use of sealants), a quarterly reporting schedule (January, April, July, and October), monitoring parameters (e.g., counties that fall below the 41.17 percent benchmark and counties in which utilization has declined for two successive quarters), and how results will be used (e.g., the fiscal intermediary's outreach unit will use the results to "inform" current and future outreach activities described in the Beneficiary Outreach and Education Program Plan).

60-Day Agency Response

DHCS is in the process of gathering and assessing existing beneficiary data and assessing health care industry methodologies to establish measures that best represent the plight of the beneficiary experience and utilization in the Medi-Cal Dental Program. Once the DHCS establishes a standardized measure by which it will assess beneficiary utilization, the DHCS will develop annual benchmarks for beneficiary utilization. Once benchmarks are established, the DHCS will identify beneficiary populations that have not performed to the standard and employ appropriate mitigation strategies. The DHCS will consult and engage with stakeholders during the development of the measure for beneficiary utilization and benchmarks. The DHCS will publicly report this measurement in accordance with DHCS reporting policies. The DHCS expects to meet the established implementation date of May 1, 2015

Estimated Completion Date: May 2015
Response Date: February 2015

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #2 To: Health Care Services, Department of

6-Month Agency Response

DHCS has established criteria for assessing provider participation in the Medi-Cal Dental Program. DHCS developed a standardized measure and county-specific benchmarks that will be used to assess provider participation and evaluate network capacity in the Medi-Cal dental fee-for-service delivery system. DHCS utilized existing provider and beneficiary data and, as a collaborative effort, incorporated input from the dental stakeholder community to develop the measures. DHCS will begin reporting on final measures in 2015. DHCS will also take proactive steps to evaluate additional data resources for assessing provider participation and capacity by region and statewide as appropriate. On July 20, 2015, DHCS released the results of the first dental provider network capacity survey conducted in the last quarter of 2014.

Completion Date: May 2015
Response Date: July 2015

California State Auditor's Assessment of 6-Month Status: Fully Implemented

Health Care Services provided a document labeled "Medi-Cal Dental Program Provider Participation Measurement." This document states that Health Care Services will use "county-specific licensed dentist-to-general population ratio" as the benchmark to compare Medi-Cal provider participation ratios. It also states that the numerator of the ratio will be the number of rendering providers and "safety net clinics" who serviced 25, 50, 75, and 100 or more unduplicated beneficiaries in a 12-month period; the denominator will be the number of "Medi-Cal eligibles" in the county.

Health Care Services also provided a document labeled "Dental Provider Network Capacity Survey Summary" (summary) dated June 2015. This summary described the results of Health Care Services' survey of providers around the State and included information such as whether providers increased the number of Medi-Cal patients seen in a week and whether they were willing to accept new Medi-Cal patients.

60-Day Agency Response

DHCS is currently in the process of gathering and assessing existing provider data and assessing health care industry methodologies to establish measures that best represent provider participation and capacity in the Medi-Cal Dental Program. Once DHCS establishes a standardized measure by which it will assess provider participation and capacity by region and statewide, DHCS will develop benchmarks. The established benchmarks will be used to evaluate network adequacy and identify geographic areas where the fee-for-service provider network can be strengthened to inform future outreach efforts and develop mitigation strategies as appropriate. DHCS will consult and engage with stakeholders during the development of the measure for provider participation and benchmarks thereof. DHCS intends to report this measure publically, consistent with DHCS' reporting policies. DHCS expects to meet the established implementation date of May 1, 2015.

Estimated Completion Date: May 2015
Response Date: February 2015

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #3 To: Health Care Services, Department of

To ensure that child beneficiaries throughout California can reasonably access dental services under Medi-Cal and to increase child beneficiary utilization and provider participation, Health Care Services should take the following steps for the fee-for-service delivery system by May 2015: develop procedures for identifying periodically counties or other geographic areas in which the utilization rate for child beneficiaries and the participation rate for providers fail to meet applicable criteria.

6-Month Agency Response

DHCS has established procedures for periodically identifying counties or other geographic areas where child beneficiary utilization and provider participation fail to meet applicable criteria.

Completion Date: May 2015
Response Date: July 2015

California State Auditor's Assessment of 6-Month Status: Fully Implemented

Health Care Services also provided a document labeled "Provider Participation Measurement Policies and Procedures." This document identifies information such as reporting standards, data sources, and a measurement methodology.

60-Day Agency Response

DHCS is currently in the process of gathering and assessing existing provider and beneficiary data and assessing health care industry methodologies to establish measures that best represent beneficiary utilization and provider participation and capacity in the Medi-Cal Dental Program. Once DHCS has established standardized measures by which it will assess beneficiary utilization and provider participation and capacity by region and statewide, DHCS will establish procedures to annually identify counties and other geographic areas where child beneficiary utilization and provider participation fail to meet the criteria established in recommendations A1 and A2. The DHCS will employ mitigation strategies for identified underperforming geographic areas. DHCS expects to meet the established implementation date of May 1, 2015.

Estimated Completion Date: March 2015
Response Date: February 2015

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #4 To: Health Care Services, Department of

To ensure that child beneficiaries throughout California can reasonably access dental services under Medi-Cal and to increase child beneficiary utilization and provider participation, Health Care Services should take the following steps for the fee-for-service delivery system by May 2015: immediately take action to resolve any declining trends identified during its monitoring efforts.

Annual Follow-Up Agency Response From October 2019

DHCS has taken actions in launching the Smile, California campaign to increase eligible beneficiaries' use of Medi-Cal's dental benefit, increase awareness, and educate eligible beneficiaries about the free and low-cost services available to help maintain a healthy smile, and reduce any barriers accessing care. In addition, the Administrative Services Contractor conducted outreach to providers. Providers are also incentivized through the DTI and Proposition 56 supplemental payments, which has contributed to positive trends in annual dental visits between calendar year 2016 to 2018.

Completion Date: July 2019

California State Auditor's Assessment of Annual Follow-Up Status: Fully Implemented

Annual Follow-Up Agency Response From November 2018

As a follow up to the initiatives addressed in the previous response, DHCS plans to, but has had to postpone, conducting trend analysis to enable inclusion of complete DTI Program Year (PY) two, Proposition 56 2017-18 supplemental payments, and adult restoration data.

DHCS will perform a data analysis of the past three fiscal years (2015-16, 2016-17, and 2017-18) and publish those results by end of July 2019.

Estimated Completion Date: July 2019

California State Auditor's Assessment of Annual Follow-Up Status: Pending

Annual Follow-Up Agency Response From September 2017

DHCS addressed this recommendation by implementing and monitoring annual beneficiary and provider outreach plans. In 2017, DHCS is focused on beneficiary outreach in 23 underserved counties and increasing provider recruitment through various outreach efforts, i.e. letter campaigns, one-on-one enrollment assistance, presentations to dental schools and allied dental professional programs. DHCS is enhancing provider retention through training seminars, on-site visits, satisfaction surveys, and redesigning customer support through consumer friendly print materials, online, and mobile applications. DHCS is using alternative service delivery modalities to increase beneficiaries' access to services, including six mobile dental vans, school based health centers, and teledentistry (733 claims billed as of June 2017). DHCS implemented and is monitoring the DTI which has demonstrated both a 1.3 percent increase in utilization of preventive services for children in 2016 and an increase in Medi Cal dentists providing preventive dental services to at least ten children by 5.4 percent. 2017 DTI incentive payments by Domain (D) to date: D1 - $24 million to 2,646 dental locations statewide for providing preventive services; D2 - $486,122 to providers utilizing Caries Risk Assessments to diagnose early childhood caries; 88 providers have opted-in; D3 - $9.2 million to 684 dental service office locations in 17 pilot counties for ensuring continuity of care; and, D4 - 11 of 15 local dental pilot projects have been implemented (4 are still under DHCS review). DHCS continues to implement AB 2207 provisions, including a number of per-provider reports due from DHCS to be posted by July 2019.

Completion Date: August 2017

California State Auditor's Assessment of Annual Follow-Up Status: Partially Implemented

We cannot confirm that DHCS fully implemented this recommendation. Although DHCS provided documents supporting its implementation of measures related to dental access (e.g., number of dental providers, beneficiary utilization by region and total, and a comparison of Medi-Cal dental reimbursement rates to other states' rates), these documents noted that DHCS will perform its first analysis on data for FYs 2015-16 and 2016-17. DHCS did not provide documents related to the results of its data analysis for these two fiscal years nor any actions it took in response to declining trends it identified therefrom.

Auditee did not substantiate its claim of full implementation

Annual Follow-Up Agency Response From November 2016

DHCS compiled reports related to beneficiary utilization and provider participation measures as part of its monitoring efforts. These reports support DHCS in identifying county-specific improvement areas and aid in selection of counties for the annual outreach plans to resolve identified declining trends. Additionally, DHCS Dental Transformation Initiative (DTI) received CMS approval December 30, 2015; the first demonstration year began January 1, 2016. DHCS will evaluate how the DTI, funded up to $750 million over five years, impacts children's utilization of preventive services, decreases caries, and improves continuity of care. DHCS has engaged in efforts to increase beneficiary utilization including the use of dental vans in select underserved counties, outreach to numerous County and Community agencies, school districts, and County health events. DHCS is committed to improvement of identified concerns and provided extensive technical assistance to the author's office on the provisions contained in the recently chaptered Assembly Bill (AB) 2207 (Chapter 613, Statutes of 2016). AB 2207 aims to improve Denti-Cal by confirming proper transparency and monitoring utilization of dental care, requiring DHCS to make changes to Denti-Cal's provider enrollment and disenrollment processes, increase access and utilization oversight responsibility of DHCS over its contractors, and align Denti-Cal FFS and DMC data reporting requirements. This legislation grants DHCS the ability to utilize bulletins, or the like to implement, interpret, and make specific policies and procedures for the DHCS Dental Program until regulations are adopted. This enables DHCS to achieve immediate action to resolve any declining trends identified during its monitoring efforts.

Estimated Completion Date: January 2017

California State Auditor's Assessment of Annual Follow-Up Status: Not Fully Implemented

1-Year Agency Response

As the nature of this recommendation is ongoing, there is no definitive implementation date. Once the reporting of the beneficiary utilization and provider participation measures is complete, the results of these measures will help identify any declining trends in county-specific access to care issues and will be used as the standard benchmark criteria in the annual outreach plans. In addition, in October 2015, the Centers for Medicare and Medicaid Services (CMS) approved the exemption of dental services and applicable ancillary services from the Assembly Bill 97 ten percent provider payment reductions for dates of service on or after July 1, 2015. DHCS has implemented this exemption on a prospective basis since November 19, 2015 and expects providers to begin receiving retroactive payments for claims that were submitted before the date of implementation beginning December 2015. In addition, DHCS' dental provider incentive proposals through the Medi-Cal Waiver 2020 efforts propose $740 million to fund the incentive programs over a five-year period. Through this proposal, DHCS has the opportunity to earn an additional $10 million in funding by meeting additional performance metric criteria. The projected effective date for the Medi-Cal Waiver 2020 dental incentive programs is January 2016.

Estimated Completion Date: January 2016
Response Date: December 2015

California State Auditor's Assessment of 1-Year Status: Pending

6-Month Agency Response

DHCS has established criteria for assessing provider participation and beneficiary utilization and has developed procedures for periodically identifying counties where beneficiary utilization and provider participation fail to meet applicable criteria. In accordance with the processes outlined in these procedures, DHCS will actively assess access to care and will take necessary steps to resolve declining trends that are within its purview to implement during monitoring efforts. Some mitigation strategies in order to implement may require additional resources or funding, which would be subject to approval through the annual budget process. Pursuant to the enactment of the 2015-16 California State Budget, DHCS is currently taking proactive steps to acquire federal approval to exempt dental services and applicable ancillary services from the Assembly Bill 97 10% provider payment reductions (Chapter 3, Statutes of 2011), with an effective date for dates of service on or after July 1, 2015.

Estimated Completion Date: Summer 2015
Response Date: July 2015

California State Auditor's Assessment of 6-Month Status: Pending

60-Day Agency Response

Once DHCS has established beneficiary utilization and provider participation measures, it will actively assess access to care and immediately take necessary steps to resolve declining trends that are within its purview to implement. DHCS recognizes that some solutions may require additional resources and funding and will take the necessary steps to seek approval within the Administration in order to implement identified mitigation strategies to resolve declining trends identified during its monitoring efforts.

Estimated Completion Date: Ongoing
Response Date: February 2015

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #5 To: Health Care Services, Department of

To help increase the number of providers participating in the program's fee-for-service delivery system, Health Care Services should improve its identification and implementation of changes that minimize or simplify administrative processes for providers. These changes should include revising its processes pertaining to dental procedures that require radiographs or photographs.

Annual Follow-Up Agency Response From November 2020

DHCS implemented CDT 16 through CDT 19 code updates in March and May 2020, respectively, and released a provider bulletin article notifying providers of the changes. The dental Manual of Criteria and Schedule of Maximum Allowances with the code updates were implemented through bulletin authority and published on the Medi Cal Dental Website.

Completion Date: May 2020

California State Auditor's Assessment of Annual Follow-Up Status: Fully Implemented

Annual Follow-Up Agency Response From October 2019

DHCS has begun various phases of implementation for CDT 16; however, in an attempt to bring DHCS as current as possible with dental code sets, DHCS decided to bring it current through CDT 19. The complete update is on schedule for March 2020.

Proposition 56 supplemental payments have been implemented since FY 2017-18 and has been approved to continue through December 31, 2021. The supplemental payments vary between 20 to 60 percent of the Schedule of Maximum Allowances or a specific dollar increase effective July 1, 2018, through June 30, 2019.

Estimated Completion Date: March 2020

California State Auditor's Assessment of Annual Follow-Up Status: Pending

Annual Follow-Up Agency Response From November 2018

CDT 2016 implementation date has moved from the anticipated January 2018 to approximately December 31, 2018 due to extensive system changes necessary to implement the CDT updates.

MDSD issued multiple provider bulletins in 2017 and in 2018 regarding implementation of Proposition 56 supplemental payments. Proposition 56 dental page also notes the SPA approval for 2017 and 2018: https://www.dhcs.ca.gov/services/Pages/Proposition-56-Dental.aspx

Estimated Completion Date: 12/31/2018

California State Auditor's Assessment of Annual Follow-Up Status: Pending

Annual Follow-Up Agency Response From September 2017

This recommendation has been implemented by the administrative simplifications noted in prior updates and our ongoing efforts noted in this update. On January 1, 2017 DHCS implemented a new Denti-Cal Provider Enrollment Application, consolidated the Medi Cal Dental provider application and enrollment process, and reduced the number of forms from four to one. Providers will no longer download multiple forms and sign multiple times to add a practice and accept beneficiaries. With the implementation of AB 2207, a provider application won't be returned for missing information if it is provided elsewhere in the application packet. DHCS will use the bulletin authority provided from AB 2207 to update the current CDT 2013 regulatory package to CDT 2016, inclusive of administrative simplifications to reduce the amount of paperwork on providers for submitting Treatment Authorization Requests and claims. DHCS intends to submit and implement this regulatory package in January 2018 to account for the restoration of adult benefits. DHCS is implementing initiatives to influence provider participation through supplemental payments to providers on specific procedures utilizing funding from Proposition 56 in accordance with AB 120. These funds are in addition to the current Dental Schedule of Maximum Allowances (SMA) and will be at a payment rate equal to 40 percent of the SMA for the specified codes for dates of service during July 1, 2017 through June 30, 2018. Upon federal approval, effective January 1, 2018, DHCS will restore adult dental benefits previously eliminated from the 2009 SPA, resulting in full-scope adult dental benefits.

Completion Date: August 2017

California State Auditor's Assessment of Annual Follow-Up Status: Partially Implemented

We cannot confirm that DHCS has fully implemented this recommendation. Although we obtained documentation that DHCS streamlined the application and process to become a Medi-Cal dental provider, it did not provide documents related to its implementation of CDT 2016 or its implementation of supplemental payments to Medi-Cal dentists for certain procedures.

Annual Follow-Up Agency Response From November 2016

In conjunction with Denti-Cal stakeholders, DHCS implemented administrative simplifications into the dental program such as payment for restorations not requiring radiograph submission unless selected for random sampling, eliminated the prior authorization requirement for immediate dentures (where there are teeth that need extraction); and added clarifying language and materials to assist in the prior authorization requirement for general anesthesia/intravenous sedation. Additionally, effective July 1, 2015, enrolled Denti-Cal billing providers are permitted to use Teledentistry as an alternative modality for the provision of dental services via store and forward. Teledentistry live transmission services are pending final CMS SPA approval which is anticipated to be secured by December 2016. In addition, DHCS is consolidating the proposed set of Current Dental Terminology code additions and anticipates a regulation package will be submitted formally for a public comment period and review with the Office of Administrative Law anticipated in the second quarter of 2017. As noted earlier, DHCS provided extensive technical assistance to the author's office on the provisions contained in AB 2207. In terms of simplifications, AB 2207 grants DHCS the ability to utilize all plan letters, provider bulletins, or the like to implement, interpret, and make specific policies and procedures for the DMC and FFS delivery systems until regulations are adopted; however, utilization of these notification processes will require DHCS to provide a status report to the legislature on a semiannual basis until such regulations have been adopted. This will help DHCS to increase the number of providers participating in the Medi-Cal Dental Program fee-for-service delivery system by ensuring quicker identification and implementation of changes that minimize or simplify administrative processes for providers.

Estimated Completion Date: January 2017

California State Auditor's Assessment of Annual Follow-Up Status: Not Fully Implemented

1-Year Agency Response

DHCS has proposed a set of Current Dental Terminology code additions which are currently in the internal review process and will be submitted formally to the Office of Administrative Law early in 2016. Additionally administrative simplifications will be incorporated into the dental program such as payment for restorations not requiring radiograph submission unless selected for random review; prior authorization not required for immediate dentures (where there are teeth that need extraction); and a prior authorization requirement for general anesthesia/intravenous sedation. Teledentistry is a recently offered modality and live transmission services will prospectively be reimbursable. In addition, pursuant to the special terms and conditions under the Medi-Cal 2020 waiver for the dental component, incentives will also be offered to select providers through an incentive program pilot to perform caries risk assessments, motivational interviewing, and other preventive care.

Estimated Completion Date: End of 2016
Response Date: December 2015

California State Auditor's Assessment of 1-Year Status: Pending

6-Month Agency Response

DHCS is in the process of re-evaluating existing policies and simplifying administrative processes to encourage provider participation. DHCS has established regular meetings with dental consultants to re-evaluate existing policies with the objective to implement administrative simplifications while upholding program integrity and adhering to medical necessity criteria which is federally required and designed to protect and ensure the health and well-being of Medi-Cal beneficiaries. Current policy requires that any administrative simplification(s) must be implemented through the regulatory process which can take anywhere from one to two years. An alternate means to expedite implementation of recommended simplifications would require a statute change. Implementation must therefore be changed to no earlier than July 1, 2016.

Estimated Completion Date: July 2016
Response Date: July 2015

California State Auditor's Assessment of 6-Month Status: Pending

60-Day Agency Response

DHCS is in the process of re-evaluating existing policies and simplifying administrative processes to encourage provider participation. With the implementation of new Current Dental Terminology (CDT) codes issued by the American Dental Association for 2015, DHCS will identify opportunities to offer providers a simplified process in their claims submission. DHCS has established regular meetings with program and contractor dental consultants to re-evaluate existing policies whose main objective is to implement administrative simplifications while upholding program integrity and adhering to medical necessity criteria which are designed to protect and ensure the health and well-being of Medi-Cal beneficiaries. DHCS intends to meet its established implementation date of July 1, 2015.

Estimated Completion Date: July 2015
Response Date: February 2015

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #6 To: Health Care Services, Department of

To ensure that the influx of beneficiaries resulting from recent changes to federal and state law is able to access Medi-Cal's dental services, Health Care Services should take these steps: continuously monitor beneficiary utilization, the number of beneficiaries having difficulty accessing appointments with providers, and the number of providers enrolling in and leaving the program.

1-Year Agency Response

DHCS has fully implemented this recommendation. DHCS continues to regularly monitor the volume of beneficiaries having difficulty accessing appointments and the number of providers enrolling and disenrolling from the program to identify any trends affecting network adequacy.

Completion Date: July 2015
Response Date: December 2015

California State Auditor's Assessment of 1-Year Status: Fully Implemented

Health Care Services provided examples of periodic reports that measured beneficiary utilization, the number of beneficiaries having difficulty accessing appointments with providers, and the number of providers leaving the program and reasons for leaving.

6-Month Agency Response

DHCS shall use the beneficiary measures established to monitor utilization. DHCS has submitted a Delta Operational Instruction Letter to the contractor directing them to capture the number of beneficiaries having difficulty in accessing dental appointments. DHCS has been tracking provider enrollment and disenrollment information to help in analyzing access to care and network adequacy since September 2013. Data collected to date does not indicate a shift in enrollment/disenrollment.

Completion Date: July 2015
Response Date: July 2015

California State Auditor's Assessment of 6-Month Status: Partially Implemented

Although Health Care Services provided policy documents pertaining to measuring beneficiary utilization and identifying and tracking weekly the numbers of beneficiaries having difficulty accessing appointments with providers, it did not provide documents showing that these policies were implemented. For instance, the instruction letter Health Care Services mentions directs Delta Dental, the fiscal intermediary, to track and report weekly several measures pertaining to access concerns, including urgent appointments not scheduled within 72 hours, non-urgent appointments not scheduled within 36 business days, and preventive appointments not scheduled within 40 business days out. Delta Dental is also to track appointments more than 25 miles from the beneficiary's address and whether the beneficiary's age is 20 and under or 21 and over. These documents indicate that DHCS will be able to monitor difficulties in beneficiary access to Medi-Cal dental care. However, Health Care Services did not provide documents showing the results of its monitoring of beneficiary utilization or copies of Delta Dental's weekly reports.

Auditee did not substantiate its claim of full implementation

60-Day Agency Response

DHCS is currently in the process of gathering and assessing existing provider and beneficiary data and assessing health care industry methodologies to establish measures that best represent beneficiary utilization and provider participation and capacity in the Medi-Cal Dental Program. Once the DHCS has established standardized measures by which it will assess beneficiary utilization and provider participation and capacity by region and statewide, the DHCS will continuously monitor beneficiary utilization. DHCS is developing a draft instruction letter to its contractor that establishes a new category to capture the number of beneficiaries reporting difficulty in accessing dental appointments. Effective September 2013, DHCS started to monitor provider enrollment and disenrollment information to help in our assessment of access to care. The DHCS expects to meet the established implementation date of July 1, 2015.

Estimated Completion Date: July 2015
Response Date: February 2015

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #7 To: Health Care Services, Department of

To ensure that the influx of beneficiaries resulting from recent changes to federal and state law is able to access Medi-Cal's dental services, Health Care Services should immediately take action to resolve any declining trends identified during its monitoring efforts.

Annual Follow-Up Agency Response From October 2019

DHCS has taken actions in launching the Smile, California campaign to increase eligible beneficiaries' use of Medi-Cal's dental benefit, increase awareness, and educate eligible beneficiaries about the free and low-cost services available to help maintain a healthy smile, and reduce any barriers accessing care. In addition, the Administrative Services Contractor conducted outreach to providers. Providers are also incentivized through the DTI and Proposition 56 supplemental payments, as well as restored adult dental benefits, which has contributed to positive trends in annual dental visits between calendar year 2016 to calendar year 2018.

Completion Date: July 2019

California State Auditor's Assessment of Annual Follow-Up Status: Fully Implemented

Annual Follow-Up Agency Response From November 2018

As a follow up to the initiatives addressed in the previous response, DHCS plans to, but has had to postpone, conducting trend analysis to enable inclusion of complete DTI PY two, Proposition 56 2017-18 supplemental payments, and adult restoration data.

DHCS will perform a data analysis of the past three fiscal years (2015-16, 2016-17, and 2017-18) and publish those results by end of July 2019.

Estimated Completion Date: July 2019

California State Auditor's Assessment of Annual Follow-Up Status: Pending

Annual Follow-Up Agency Response From September 2017

This recommendation has been implemented and DHCS continues to monitor dental utilization of all Medi-Cal beneficiaries and explore innovative approaches to increase access and utilization, as mentioned via outreach plans and monitoring and assessment of DTI. Additionally, in 2017, DHCS increased outreach efforts including multiple visits to county and community agencies, school districts, and participation in county health events. Additional details for conducted outreach are also provided in A4. Further, as part of monitoring and child-beneficiary specific outreach, DHCS has implemented outreach campaigns to increase utilization using Mailers/Robo Calls to households with children ages 0-3 with no utilization of services within the previous 12 months, and mailers to all new enrollees each quarter through the end of 2017. Teledentistry live transmission services also offers another modality for a beneficiary to receive services. DHCS is implementing initiatives to influence provider participation through supplemental payments to providers on specific procedures utilizing funding from Proposition 56 in accordance with AB 120. These funds are in addition to the current Dental Schedule of Maximum Allowances (SMA) and will be at a payment rate equal to 40 percent of the SMA for the specified codes for dates of service during July 1, 2017 through June 30, 2018. Upon federal approval, effective January 1, 2018, DHCS will restore adult dental benefits previously eliminated from the 2009 SPA, resulting in full-scope adult dental benefits.

Completion Date: August 2017

California State Auditor's Assessment of Annual Follow-Up Status: Partially Implemented

We cannot confirm that DHCS fully implemented this recommendation. Although DHCS provided documents supporting its implementation of measures related to monitoring dental access (e.g., number of dental providers, beneficiary utilization by region and total, and a comparison of Medi-Cal dental reimbursement rates to other states' rates), these documents noted that DHCS will perform its first analysis on data for FYs 2015-16 and 2016-17. DHCS did not provide documents related to the results of its data analysis for these two fiscal years nor any actions it took in response to declining trends it identified therefrom.

Annual Follow-Up Agency Response From November 2016

DHCS has designed and implemented components of the beneficiary utilization and provider participation outreach plans. The results of these outreach plans support DHCS in identifying county-specific access to care issues and serve as a useful resource for the DTI and other utilization monitoring efforts. DHCS has also completed the implementation of the exemption of dental services and applicable ancillary services from the Assembly Bill 97 ten percent provider payment reductions for dates of service on or after July 1, 2015, and retroactively reimbursed the affected providers as of April 2016. Lastly, DHCS reports that appropriate actions and measures are effectively underway as part of the successful commencement of the dental provider incentive proposals through the Medi-Cal Waiver 2020. Additionally, in conjunction with Denti-Cal stakeholders, DHCS implemented administrative simplifications added clarifying language and materials to assist in the prior authorization requirement for general anesthesia/intravenous sedation. Teledentistry is now offered as an alternative modality for dental services and the live transmission option is currently pending CMS approval which is anticipated for December 2016. In addition, with the DTI, DHCS is consolidating the proposed set of Current Dental Terminology code additions and anticipates the regulatory package will be submitted formally for a public comment period and review with the Office of Administrative Law anticipated in the second quarter of 2017.

Estimated Completion Date: January 2017

California State Auditor's Assessment of Annual Follow-Up Status: Not Fully Implemented

1-Year Agency Response

Estimated Completion Date: January 2016
Response Date: December 2015

California State Auditor's Assessment of 1-Year Status: Pending

6-Month Agency Response

DHCS has established criteria for assessing provider participation and beneficiary utilization and has developed procedures for periodically identifying counties where beneficiary utilization and provider participation fail to meet applicable criteria. In accordance with the processes outlined in these procedures and the efforts previously described, DHCS will actively assess access to care and will take necessary steps to resolve declining trends that are within its purview to implement during monitoring efforts. Some mitigation strategies in order to implement may require additional resources or funding, which would be subject to approval through the annual budget process. As the nature of this recommendation is ongoing, there is no definitive implementation date.

Estimated Completion Date: Ongoing
Response Date: July 2015

California State Auditor's Assessment of 6-Month Status: Pending

60-Day Agency Response

Once DHCS has established beneficiary utilization and provider participation measures and have institutionalized mechanisms to capture the number of beneficiaries having difficulty accessing appointments, it will take necessary steps to resolve declining trends that are within its purview to implement. The DHCS recognizes that some solutions may require additional resources and funding and will take the necessary steps to seek approval within the Administration in order to implement identified mitigation strategies to resolve declining trends identified during its monitoring efforts. As the nature of this recommendation is ongoing, there is no definitive implementation date

Estimated Completion Date: Ongoing
Response Date: February 2015

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #8 To: Health Care Services, Department of

To ensure that Medi-Cal's child beneficiaries have reasonable access to dental services, Health Care Services should immediately resume performing its annual reimbursement rate reviews, as state law requires.

6-Month Agency Response

DHCS gathered pertinent data that informed the annual reimbursement rate assessment as required by State law. DHCS recognizes that the findings of the rate review and implementation of any such changes will be subject to approval within the Administration, the Legislature, and with the federal Centers for Medicare and Medicaid Services for purposes of receiving federal reimbursement while ensuring the proper and efficient administration of the program. The annual reimbursement rate assessment was submitted to the legislature on July 2, 2015 and DHCS will continue conducting such assessments annually thereafter.

Completion Date: July 2015
Response Date: July 2015

California State Auditor's Assessment of 6-Month Status: Fully Implemented

Health Care Services issued a rate review for Medi-Cal Dental Services dated July 1, 2015. In this review, Health Care Services stated that given recent legal actions (which it describes), a reimbursement rate and its relationship to beneficiary access is not a strict or linear one, and that a multitude of factors must be considered and addressed when ensuring appropriate access to covered services. Although Health Care Services does not specifically mention whether California's reimbursement rates are sufficient to ensure the reasonable access of Medi-Cal beneficiaries to dental services, the review includes such information as comparisons of California's reimbursement rates to other states' Medicaid reimbursement rates and to the commercial rates in other regions around the US, and descriptions of Health Care Services' efforts to improve beneficiary utilization (e.g., developing and implementing beneficiary and provider outreach plans, contracting with additional providers, and enrolling para-professionals).

60-Day Agency Response

DHCS is currently gathering pertinent data that will be used to perform the annual reimbursement rate assessment as required by State law. DHCS also recognizes that the findings of the rate review and implementation of any such changes will be subject to approval within the Administration, the Legislature, and with the federal Centers for Medicare and Medicaid Services for purposes of receiving federal reimbursement while ensuring the proper and efficient administration of the program. DHCS anticipates fulfilling the established implementation date of July 1, 2015.

Estimated Completion Date: July 2015
Response Date: February 2015

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #9 To: Health Care Services, Department of

Annual Follow-Up Agency Response From September 2017

DHCS completed submission of the dental portion of the data for the monitoring plan submission in January 2016. The monitoring plan has been posted.

Completion Date: September 2016

California State Auditor's Assessment of Annual Follow-Up Status: Resolved

Annual Follow-Up Agency Response From November 2016

DHCS completed submission of the dental portion of the data for the monitoring plan submission in January 2016. While a posting date for this monitoring plan is not available at this time, DHCS will notify stakeholders once it is posted.

Estimated Completion Date: January 2017

California State Auditor's Assessment of Annual Follow-Up Status: Not Fully Implemented

1-Year Agency Response

DHCS has completed submission of the dental portion of the data for the monitoring plan submission. However, DHCS is in the process of completing a final compilation of the contributed data. Once compilation has been completed, the Department will be posting the monitoring plan for public availability. A posting date for this monitoring plan is not available at this time however; DHCS will notify stakeholders once it is posted

Estimated Completion Date: Ongoing
Response Date: December 2015

California State Auditor's Assessment of 1-Year Status: Pending

6-Month Agency Response

Estimated Completion Date: Ongoing
Response Date: July 2015

California State Auditor's Assessment of 6-Month Status: Partially Implemented

60-Day Agency Response

The department will incorporate all measures by county, and statewide in the 2012 report. However, beneficiary data by disability is currently represented in the report within the disabled aid categories. DHCS did not implement AB 97 reduction until 2013 ; therefore 2011 and 2012 reports will be used as baseline reports. DHCS will compare current utilization data for the 2012 reporting.

Estimated Completion Date: Pending
Response Date: February 2015

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #10 To: Health Care Services, Department of

To make certain that access to dental services for child beneficiaries is comparable to the access available to the general population in the same geographic areas, Health Care Services should also compare its results for measuring the percentage of child beneficiaries who had at least one dental visit in the past 12 months with the results from the three surveys conducted by other entities, as its state plan requires.

Annual Follow-Up Agency Response From September 2017

DHCS posted the 2016 California's FFS Medi Cal Program Health Care Access Monitoring Plan, inclusive of the dental portion mentioned in the prior update. The 2016 report can be found here:

http://www.dhcs.ca.gov/formsandpubs/laws/Documents/2016AccessMonitoringPlan.pdf.

Completion Date: September 2016

California State Auditor's Assessment of Annual Follow-Up Status: Resolved

Annual Follow-Up Agency Response From November 2016

DHCS has revised the monitoring plan submission to include comparisons of the percentage of child beneficiaries who had at least one dental visit in the past twelve months with the results from the three surveys conducted by other entities as required by the State Plan. The three surveys used for comparison are The National Health Interview Survey (NHIS), The Medical Expenditure Panel Survey (MEPS), and the California Health Interview Survey (CHIS). DHCS used the most recent versions of each of these survey reports in its 2012 monitoring report. This effort allowed the Department to convey the significance of any identified healthcare access problems and work to determine appropriate solutions to address the problem. Data presented for this purpose will help tailor solutions and shape healthcare policy in the state. In the future, DHCS intends to share data collected and analyzed from the healthcare access monitoring process with the public in the form of annual reports tailored to a general audience.

Estimated Completion Date: January 2017

California State Auditor's Assessment of Annual Follow-Up Status: Not Fully Implemented

1-Year Agency Response

Estimated Completion Date: Ongoing
Response Date: December 2015

California State Auditor's Assessment of 1-Year Status: Pending

6-Month Agency Response

DHCS will revise its monitoring plan submission to include comparisons of the percentage of child beneficiaries who had at least one dental visit in the past twelve months with the results from the three surveys conducted by other entities as required by the State Plan. The three surveys to be used for comparison are The National Health Interview Survey (NHIS), The Medical Expenditure Panel Survey (MEPS), and the California Health Interview Survey (CHIS). DHCS will use the most recent versions of each of these survey reports in its 2012 monitoring report. This effort will allow the Department to convey the significance of any identified healthcare access problems and work to determine appropriate solutions to address the problem. Data presented for this purpose will help tailor solutions and shape healthcare policy in the state. Data collected and analyzed from the healthcare access monitoring process will further be shared with the public in the form of annual reports tailored to a general audience. The estimated completion date for this effort is January 2016.

Estimated Completion Date: January 2016
Response Date: August 2015

California State Auditor's Assessment of 6-Month Status: Pending

60-Day Agency Response

DHCS has revised its monitoring plan submission to include comparisons of the percentage of child beneficiaries who had at least one dental visit in the past twelve months with the results from the three surveys conducted by other entities as required by the State Plan. DHCS will use the most recent survey reports in its 2012 monitoring report.

Estimated Completion Date: Ongoing
Response Date: February 2015

California State Auditor's Assessment of 60-Day Status: Partially Implemented

Recommendation #11 To: Health Care Services, Department of

To improve beneficiary utilization rates and provider participation under the program's fee-for-service delivery system, Health Care Services should immediately take the following actions: direct Delta Dental to submit annually a plan that describes how it will remedy the dental access problems in the State's underserved areas and in California's border communities.

6-Month Agency Response

Delta Dental has submitted their provider and beneficiary outreach and education plans (outreach plans) to DHCS and they are still under review. The outreach plans specifically outline how dental access issues will be addressed in underserved areas within California and the border communities. DHCS will conduct ongoing monitoring of the outreach plans to ensure beneficiary needs are addressed and that all contract provisions are satisfied. Delta Dental's annual submission of outreach plans has been made a condition of precedent to payment.

Completion Date: May 2015
Response Date: July 2015

California State Auditor's Assessment of 6-Month Status: Fully Implemented

Health Care Services provided copies of the provider and beneficiary outreach and education plans. These plans include information such as goals, objectives, processes, tasks, deadlines, and responsible parties. Health Care Services stated that workgroups will be convened in September 2015 and that revisions to the plans will be based on workgroup input. Plan approval by Health Care Services will then follow. It also stated that Delta Dental will be directed to implement the plans immediately after finalization.

60-Day Agency Response

DHCS has received an initial draft from Delta Dental of an outreach plan that describes how it will address the dental access problems in underserved areas within California and the border communities. The DHCS is in the process of evaluating the initial draft of the plan to ensure beneficiary needs are addressed and all contract provisions are satisfied. DHCS expects to comply with the established implementation date of July 1, 2015.

Estimated Completion Date: July 2015
Response Date: February 2015

California State Auditor's Assessment of 60-Day Status: Partially Implemented

Recommendation #12 To: Health Care Services, Department of

To improve beneficiary utilization rates and provider participation under the program's fee-for-service delivery system, Health Care Services should immediately take the following actions: direct Delta Dental to contract with one or more entities to provide additional dental services in either fixed facilities or mobile clinics in underserved areas, as its contract requires.

6-Month Agency Response

DHCS has directed Delta Dental to contract with one or more entities to provide additional dental services in either fixed facilities or mobile entities in underserved areas. Beginning July 1, 2015, mobile entities will provide preventative and restorative dental services in specified areas throughout the state. The first three counties with scheduled events taking place in the months following the July 1, 2015 implementation date are Alpine, Amador, and Calaveras Counties. DHCS will continue to evaluate counties throughout the state for opportunities to provide dental care through the use of contracted mobile entities.

Completion Date: May 2015
Response Date: July 2015

California State Auditor's Assessment of 6-Month Status: Fully Implemented

Health Care Services provided copies of contracts signed in May 2015 between Delta Dental and two operators of mobile dental clinics to provide dental services in designated counties.

60-Day Agency Response

DHCS has directed Delta Dental to contract with one or more entities to provide additional dental services in either fixed facilities or mobile entities in underserved areas. Delta Dental will be partnering with a potential subcontractor to pilot the provision of dental services via mobile setting in January 2015. DHCS expects to fulfill its commitment by the established July 1, 2015 implementation date.

Estimated Completion Date: July 2015
Response Date: February 2015

California State Auditor's Assessment of 60-Day Status: Partially Implemented

Recommendation #13 To: Health Care Services, Department of

To improve beneficiary utilization rates and provider participation under the program's fee-for-service delivery system, Health Care Services should immediately take the following actions: increase Delta Dental's access to beneficiary address information and require it to contact beneficiaries residing in underserved areas directly to make them aware of the program's benefits.

6-Month Agency Response

On June 9, 2015, Department of Health Care Services (DHCS) provided Delta Dental with address information for beneficiaries in underserved areas (defined in California Dental Medicaid Management Information System contract 04-35745 as areas with a utilization rate of 41.17% or less). This information will enable Delta to perform direct outreach by phone or mail to beneficiaries in underserved areas. In addition, to more fully support Delta Dental's outreach efforts to beneficiaries throughout the state, DHCS will begin providing address information for all Medi-Cal beneficiaries on a monthly basis no later than September 30, 2015.

Completion Date: June 2015
Response Date: July 2015

California State Auditor's Assessment of 6-Month Status: Fully Implemented

Health Care Services provided documentation showing it passed information to Delta Dental in June 2015. Furthermore, the 2015 Dental Outreach and Education Plan provided by Health Care Services identifies beneficiary outreach activities, including separate outreach efforts to newly enrolled beneficiaries and to existing beneficiaries.

60-Day Agency Response

DHCS is working with Delta Dental to provide them with beneficiary address information so that Delta Dental can contact beneficiaries who reside in underserved areas directly for the purposes of informing beneficiaries about their dental benefits. The DHCS is currently testing this approach with Delta Dental by administering an outreach campaign by mail and automatic follow-up telephone calls to guardians of beneficiaries' ages zero through three years of age to determine its effectiveness as a strategy to inform beneficiaries of their dental benefits. DHCS will need to secure additional funding through the administration in order to implement this recommendation by July 1, 2015.

Estimated Completion Date: July 2015
Response Date: February 2015

California State Auditor's Assessment of 60-Day Status: Partially Implemented

Recommendation #14 To: Health Care Services, Department of

To improve beneficiary utilization rates and provider participation under the program's fee-for-service delivery system, Health Care Services should immediately take the following actions: review Delta Dental's outreach activities and implement measurable objectives for its outreach unit.

1-Year Agency Response

The Department of Health Care Services (DHCS) is in receipt of Delta Dental's provider and beneficiary outreach and education plans (outreach plans) and has confirmed the presence of measurable objectives within each plan. DHCS will be performing ongoing monitoring of these objectives throughout plan implementation.

Completion Date: May 2015
Response Date: December 2015

California State Auditor's Assessment of 1-Year Status: Fully Implemented

In December 2015, Health Care Services approved Delta Dental's plan for outreach and education and for provider outreach and utilization improvement. Objectives mentioned in these plans included increasing beneficiary utilization in each underserved county by at least one percent the first year, by a total of four percent by the end of year two, and by two percent each year thereafter for a total of ten percent over the course of five years.

6-Month Agency Response

Completion Date: May 2015
Response Date: July 2015

California State Auditor's Assessment of 6-Month Status: Partially Implemented

Health Care Services provided the 2015 provider and beneficiary outreach and education plans. Although these plans contain measurable objectives, Health Care Services has not yet approved these plans and Delta Dental has not yet implemented them. Health Care Services stated that workgroups will be convened in September 2015 and that revisions to the plans will be based on workgroup input. Plan approval by Health Care Services will then follow. Health Care Services also stated that Delta Dental will be directed to implement the plans immediately upon finalization.

60-Day Agency Response

DHCS is working with Delta Dental to ensure the annual outreach plan contains measurable objectives for its outreach unit. The DHCS is in receipt of the initial outreach plan draft and is in the process of evaluating the extent to which the proposed activities are measurable in order to comply with this recommendation. The DHCS intends to adhere to the established July 1, 2015 implementation date.

Estimated Completion Date: July 2015
Response Date: February 2015

California State Auditor's Assessment of 60-Day Status: Partially Implemented

Recommendation #15 To: Health Care Services, Department of

To improve beneficiary utilization rates and provider participation under the program's fee-for-service delivery system, Health Care Services should immediately take the following actions: require Delta Dental to develop a dental outreach and education program and to submit an annual plan by the end of each calendar year.

6-Month Agency Response

The Department of Health Care Services (DHCS) is in receipt of Delta Dental's provider and beneficiary outreach and education plans (outreach plans). The outreach plans specifically outline how dental access issues will be addressed in underserved areas within California and the border communities. DHCS will conduct ongoing monitoring of the outreach plans to ensure beneficiary needs are addressed and that all contract provisions are satisfied. Delta Dental's annual submission of outreach plans has been made a condition of precedent to payment.

Completion Date: May 2015
Response Date: July 2015

California State Auditor's Assessment of 6-Month Status: Fully Implemented

Health Care Services provided copies of the 2015 provider and beneficiary outreach and education plans. These plans include information such as goals, objectives, processes, tasks, deadlines, and responsible parties. Health Care Services stated that workgroups will be convened in September 2015 and that revisions to the plans will be based on workgroup input. Plan approval by Health Care Services will then follow. Health Care Services also stated that Delta Dental will be directed to implement the plans immediately after finalization.

60-Day Agency Response

DHCS has received an initial draft of the proposed outreach plan submitted by Delta Dental for calendar year 2015. DHCS will meet with Delta Dental to discuss the execution of the proposed outreach plan to ensure all contractual provisions are accounted for. DHCS will continue to require Delta Dental to submit a dental outreach and education plan each calendar year, which serves the diverse beneficiary population and includes measurable objectives. DHCS will implement this recommendation by June 1, 2015.

Estimated Completion Date: June 2015
Response Date: February 2015

California State Auditor's Assessment of 60-Day Status: Partially Implemented

Recommendation #16 To: Health Care Services, Department of

To ensure that the State pays only for deliverables performed by Delta Dental under the terms of its contract, Health Care Services should immediately take these steps: ensure that the financial manual and invoices are consistent with contract language.

6-Month Agency Response

The Department of Health Care Services (DHCS) upheld its commitment to ensure that its financial manual and invoices are consistent with contract language. On April 21, 2015, DHCS issued an instruction letter to its fiscal intermediary to include the beneficiary and provider outreach plans as precedent to payment conditions to the Financial Manual. DHCS will monitor the implementation of the provider and beneficiary outreach plans through this mechanism.

Completion Date: May 2015
Response Date: July 2015

California State Auditor's Assessment of 6-Month Status: Fully Implemented

Health Care Services provided its letter dated April 21, 2015, directing Delta Dental to amend the financial manual to include the beneficiary and provider outreach and education plans as precedent to payment. It also provided copies of the 2015 beneficiary and provider outreach and education plans.

60-Day Agency Response

DHCS is in the process of evaluating existing financial manual provisions and invoice payment mechanisms with the requirements delineated in the contract with Delta Dental. DHCS will process the necessary documents to align manuals and invoices with the contract. The DHCS will implement this recommendation by May 1, 2015.

Estimated Completion Date: May 2015
Response Date: February 2015

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #17 To: Health Care Services, Department of

To ensure that the State pays only for deliverables performed by Delta Dental under the terms of its contract, Health Care Services should immediately take these steps: develop and implement tangible measurements to evaluate Delta Dental's performance of all functions under the contract.

1-Year Agency Response

DHCS has fully implemented this recommendation. The identified areas requiring tangible measures, namely the provider and beneficiary outreach provisions of the contract, have been satisfied through the fiscal intermediary's submission of the outreach deliverables.

Completion Date: August 2015
Response Date: December 2015

California State Auditor's Assessment of 1-Year Status: Fully Implemented

Based on documents that Health Care Services submitted to demonstrate its implementation of Recommendations 11 through 16 of this audit report, we consider Recommendation 17 fully implemented.

6-Month Agency Response

On May 1, 2015, the Department of Health Care Services (DHCS) completed the identification of contract provisions without tangible measurements for evaluating the Fiscal Intermediary's (FI) performance of all functions under the contract. However, implementation of the tangible measurements identified through this process will require an additional 90 days and will be implemented by August 2015.

Estimated Completion Date: August 2015
Response Date: July 2015

California State Auditor's Assessment of 6-Month Status: Partially Implemented

60-Day Agency Response

DHCS is in the process of developing tangible measurements to evaluate Delta Dental's performance of all functions under the contract beyond the existing deliverable structure. The measurements can be developed by May 1, 2015, but will require an additional 90 days to implement. (Summer 2015)

Estimated Completion Date: Summer 2015
Response Date: February 2015

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #18 To: Health Care Services, Department of

To comply with state contracting laws that protect the State's interests, Health Care services should implement future contract amendments via appropriate channels, including state contracting procedures.

60-Day Agency Response

DHCS is currently upholding its commitment to ensure all changes to the contract are conducted via contract amendments. (Fully Implemented as of January 1, 2015)

Completion Date: January 2015
Response Date: February 2015

California State Auditor's Assessment of 60-Day Status: Fully Implemented

In a procedure memorandum dated December 31, 2014, the acting chief of the Medi-Cal Dental Services Division (division) advised division management that appropriate processes will be invoked related to any changes to the contract with Delta Dental. The memorandum expressed Health Care Services' commitment to appropriately adopt changes to existing contracts and directed all management personnel to abide by the proper procedures when adopting changes to contracts. The memorandum included a link to Health Care Services' intranet page containing guidelines for the process to administer contract amendments.

Recommendation #19 To: Health Care Services, Department of

To ensure that it reports in the CMS-416 an accurate number of child beneficiaries who received specific types of dental services from the centers and clinics, Health Care Services should continue working on a solution to capture the details necessary to identify the specific dental services rendered.

Annual Follow-Up Agency Response From October 2019

DHCS has implemented solutions to identify the categories of dental services provided by SNCs using procedure code "03" along with International Classification of Diseases (ICD) 10 codes for each dental performance measure, and includes the SNC data in the CMS-416 submissions. As a result, DHCS has published dental performance measure reports since federal FY 2015-16 to include dental services rendered in SNCs. The reports are updated quarterly on the DHCS Website at the link shown below and each measure has notes defining the specific ICD 10 codes used in the measure.

See website at: https://www.dhcs.ca.gov/services/Pages/DentalReports.aspx

Completion Date: January 2018

California State Auditor's Assessment of Annual Follow-Up Status: Resolved

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 2018

The ASO and Fiscal Intermediary (FI) contractors have fully assumed their respective operations, as of January 29, 2018. The FI is tasked with housing and adjudicating all claims data. The FI submits dental fee-for-service claims data to the DHCS Data Warehouse, Management Information System/Decision Support System (MIS/DSS) on a monthly basis. The dental encounters provided by Safety Net Clinics (SNCs) are also included in the DHCS Data Warehouse MIS/DSS. DHCS identifies the categories of dental services provided by SNCs using procedure code "03" along with International Classification of Diseases 10 codes to identify types of dental services for all dental performance measures. As a result, DHCS is able to isolate sets of data available for ad hoc reports as well as in published reports to include specific types of dental services from the SNCs with service dates since October 2015. The Dental Performance Measures are updated quarterly on the DHCS Website located at:

https://www.dhcs.ca.gov/services/Pages/DentalReports.aspx

and annually with more stratifications on the CHHS Open Data Portal located at:

https://data.chhs.ca.gov/dataset?organization=department-of-health-care-services&q=dental

Furthermore, DHCS has published a DTI Annual Report for PY One that included data on specific types of dental services rendered at SNCs. DHCS accurately reported the data on children its submission of the Centers for Medicare and Medicaid Services (CMS) 416 report of Federal FY 2017 in April 2018. DHCS is readily able to produce accurate reports on the number of children who received specific types of dental services; therefore, DHCS is now adequately monitoring its dental services.

Completion Date: January 2018

California State Auditor's Assessment of Annual Follow-Up Status: Partially Implemented

Auditee did not substantiate its claim of full implementation
Auditee did not address all aspects of the recommendation

Annual Follow-Up Agency Response From September 2017

Due to the complexity of the system changes and timing required to implement the necessary modifications to the CD-MMIS/CA-MMIS systems to accommodate capturing the details services rendered, DHCS will revisit this request/solution after the new dental FI and ASO contractors have assumed their respective operations. Assumption of operations is scheduled for January 2018. Additionally, in 2016, approximately 208 safety net clinics chose to participate in the DTI; therefore, at minimum, DHCS is capturing the detailed preventive dental services rendered to Medi-Cal children at these sites

Estimated Completion Date: 12/31/2018

California State Auditor's Assessment of Annual Follow-Up Status: Pending

Annual Follow-Up Agency Response From November 2016

DHCS acknowledges safety net clinics throughout the state do not currently submit claims for reimbursement through the CD-MMIS. Due to the complexity of the system changes and timing required to implement modifications to the CD-MMIS/CA-MMIS systems to accommodate capturing the detailed services rendered, DHCS will have to revisit this request/solution after the new dental FI and ASO contractors have assumed their respective operations in late 2017 or early 2018. As a significant step forward, in the interim, and as component of the DTI, DHCS began capturing detailed information of all preventive dental services provided to Medi-Cal child beneficiaries as a requirement to participate in the DTI to receive incentive payments. This commenced in 2016. Participation from the 480 safety net clinics who currently render dental services is voluntary.

Estimated Completion Date: 2018

California State Auditor's Assessment of Annual Follow-Up Status: Not Fully Implemented

1-Year Agency Response

DHCS is continuing to work towards establishing a project that would allow the system to capture detailed information of all dental services provided to Medi-Cal beneficiaries in order to ensure more complete reporting in the CMS-416 report. Due to the complexity of the project, DHCS will no longer be able to implement this project by July 1, 2016. DHCS is currently evaluating whether this can be done within the existing contract or if will need to be adopted during the next fiscal intermediary and administrative services organization contracts given the system changes that will be needed to implement this project.

Estimated Completion Date: July 2016
Response Date: December 2015

California State Auditor's Assessment of 1-Year Status: Pending

6-Month Agency Response

The Department of Health Care Services (DHCS) is currently working towards establishing a project that would allow for the system to capture detailed information for all dental services provided to ensure more complete reporting in the CMS-416 report. DHCS will implement this project by July 1, 2016.

Estimated Completion Date: July 2016
Response Date: July 2015

California State Auditor's Assessment of 6-Month Status: Pending

60-Day Agency Response

DHCS is currently working towards establishing a project that would allow the system to capture detailed information for all dental services provided to ensure more complete reporting in the CMS-416 report. DHCS will implement this project by the July 1, 2016.

Estimated Completion Date: July 2016
Response Date: February 2015

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #20 To: Health Care Services, Department of

To make certain that it meets the requirements of the new state law and that its performance measures are accurate, Health Care Services should establish the provider-to-beneficiary ratio statewide and by county as performance measures designed to evaluate access and availability of dental services and include this measure in its October 2015 report to the Legislature.

Annual Follow-Up Agency Response From November 2018

As previously reported, DHCS does not agree with the recommendation to include a provider-to-beneficiary ratio in the October 2015 report to the Legislature, as this recommendation is not a part of the required reporting in W&I Code 14132.915

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

Annual Follow-Up Agency Response From September 2017

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

Annual Follow-Up Agency Response From November 2016

DHCS does not agree with the recommendation to include a provider-to-beneficiary ratio in the October 2015 report to the Legislature as this recommendation is not a part of the required reporting in Welfare and Institutions Code 14132.915. However, DHCS is committed to monitoring provider-to-beneficiary ratios as a part of its ongoing monitoring efforts to ensure that beneficiaries are able to access care. DHCS provided extensive technical assistance to the author's office on the provisions contained in the recently chaptered Assembly Bill (AB) 2207 (Chapter 613, Statutes of 2016). AB 2207 aims to expand on the provider reporting requirements for W&I 14138.915 by increasing the level of public reporting for provider activity on a per provider basis which is far more granular that the requirements sought through this report. DHCS has also established county-specific provider-to-beneficiary ratios as a benchmark for assessing provider network capacity which is sought to enhance the transparency of the provider network and serve as a supplemental resource to that of which is required in. W&I 14138.915.

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

1-Year Agency Response

Response Date: December 2015

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

As we stated in our audit report, we believe Health Care Services should reconsider its decision to not implement our recommendation. Although Section 14132.915 of the Welfare and Institutions Code does not specifically mention provider-to-beneficiary ratio as a performance measure to report annually, it does require Health Care Services to establish a list of performance measures to ensure that the program meets quality and access criteria and that this list include, but not be limited to, certain specific performance measures. In addition, state law requires that these performance measures be designed to evaluate utilization, access, availability, and effectiveness of preventive care and treatment and that Health Care Services post these performance measures on its website site annually.

As we point out on page 55 of our report, we believe one critical measure of access and availability is each county's provider-to-beneficiary ratio for this program. Although Health Care Services included on its website performance measures related to service utilization and effectiveness of preventive care and treatment, it did not include measures related to access and availability. As a result, until Health Care Services establishes the provider-to-beneficiary ratio as a performance measure, it cannot accurately predict whether sufficient numbers of providers are available to meet the increasing needs of the program in each county.

6-Month Agency Response

Response Date: July 2015

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

As we point out on page 55 of our report, we believe one critical measure of access and availability is each county's provider-to-beneficiary ratio for this program. Although Health Care Services included on its Web site performance measures related to service utilization and effectiveness of preventive care and treatment, it did not include measures related to access and availability. As a result, until Health Care Services establishes the provider-to-beneficiary ratio as a performance measure, it cannot accurately predict whether sufficient numbers of providers are available to meet the increasing needs of the program in each county.

60-Day Agency Response

DHCS does not agree with the recommendation to include a provider-to-beneficiary ratio in the October 2015 report to the Legislature, as this recommendation is not a part of the required reporting in Welfare and Institutions Code 14132.915. However, DHCS is committed to establishing and monitoring provider to beneficiary ratios as a part of its ongoing monitoring efforts to ensure that beneficiaries are able to access care. DHCS will not implement this recommendation.

Response Date: February 2015

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

Health Care Services stated above and in our audit report that it will not implement this recommendation because the provider-to-beneficiary ratio measure is not part of the reporting required by the Welfare and Institutions Code. However, we believe a critical measure of access and availability is each county's provider-to-beneficiary ratio for the Medi-Cal Dental Program. If the Legislature similarly believes that this ratio is critical for measuring access and availability of dental services for Medi-Cal beneficiaries, it should consider requiring Health Care Services to include the provider-to-beneficiary ratio statewide and for each county as part of the annual reporting.

Recommendation #21 To: Health Care Services, Department of

To make certain that it meets the requirements of the new state law and that its performance measures are accurate, Health Care Services should do the following: require that the provider field in its data systems be populated in all circumstances.

1-Year Agency Response

DHCS has implemented the recommendation, which requires rendering provider identification for every adjudicated claim service line submitted to the Medi-Cal Dental Program. A provider bulletin was released in November 2015 to communicate the changes to the provider community for the December 1, 2015 implementation date.

Completion Date: December 2015
Response Date: December 2015

California State Auditor's Assessment of 1-Year Status: Fully Implemented

In a November 2015 Denti-Cal Bulletin, Health Care Services required rendering providers to include their National Provider Identifier number on all dated procedures submitted for payment.

6-Month Agency Response

The Department of Health Care Services (DHCS) has drafted a Dental Operating Instruction Letter (DOIL) for its Fiscal Intermediary (FI) to implement the recommendation to require rendering provider ID for every adjudicated claim service line submitted to the Medi-Cal Dental Program. The FI is currently assessing the system impact for the revisions the program seeks to implement. By September 2015, when the system assessment of this effort is complete, an implementation date will be established.

Estimated Completion Date: Ongoing
Response Date: July 2015

California State Auditor's Assessment of 6-Month Status: Pending

60-Day Agency Response

DHCS is currently evaluating whether this can be done within the existing contract or if this requires a new Request for Proposal. Once DHCS has completed the assessment, DHCS can establish a completion date.

Estimated Completion Date: Ongoing
Response Date: February 2015

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #22 To: Health Care Services, Department of

To make certain that it meets the requirements of the new state law and that its performance measures are accurate, Health Care Services should do the following: correct the erroneous data currently in its data warehouse and fix its process for transferring data from its mainframe to its data warehouse.

6-Month Agency Response

DHCS has remedied this anomaly and corrected all erroneous data in its data warehouse.

Completion Date: March 2015
Response Date: July 2015

California State Auditor's Assessment of 6-Month Status: Fully Implemented

Health Care Services provided documentation demonstrating that it had identified the cause of the erroneous data in its data warehouse, corrected its process for transferring data from its mainframe to its data warehouse, and tested the corrected process. Further, the documentation shows that the erroneous data in its data warehouse have been corrected.

60-Day Agency Response

DHCS has implemented the correction of erroneous data being submitted to the data warehouse. However, DHCS is continuing to work towards correcting erroneous data in the data warehouse retrospectively. DHCS anticipates completing the retrospective corrections by March 1, 2015.

Estimated Completion Date: March 2015
Response Date: February 2015

California State Auditor's Assessment of 60-Day Status: Partially Implemented

Recommendation #23 To: Health Care Services, Department of

To ensure that Health Care Services and its fiscal intermediaries reimburse providers only for services rendered to eligible beneficiaries, Health Care Services should obtain Social Security's Death Master File and update monthly its beneficiary eligibility system with death information.

Annual Follow-Up Agency Response From October 2021

DHCS is still in negotiations with SSA to gain access to SSA's DMF with no estimated date to secure an agreement. Therefore, the dental Administrative Services Organization contractor will continue to utilize the date of death information from a monthly FAME file. FAME is an extract of DHCS' MEDS, which is updated monthly and in real-time batch transactions. MEDS is the central repository for Medi-Cal eligibility data. MEDS records are created and updated in partnership with the statewide county eligibility offices. FAME is used to create a report to check against beneficiaries' date of death, which is a temporary solution. The report lists beneficiaries with a date of service past the date of death and the Administrative Services Organization contractor performs claim reversals to prevent inappropriate payments. Once DHCS secures access to the SSA's DMF, DHCS will update its monthly beneficiary eligibility system used by the DHCS contractors and fully implement the recommendation.

Estimated Completion Date: 08/30/2022

California State Auditor's Assessment of Annual Follow-Up Status: Pending

Annual Follow-Up Agency Response From November 2020

We experienced delays in securing an agreement to gain access to the SSA's DMF; therefore, the dental Administrative Services Organization contractor has utilized the date of death information from a monthly Fiscal Intermediary Access to Medi-Cal Eligibility (FAME) file. FAME is an extract of DHCS' Medi-Cal Eligibility Data Systems (MEDS), which is updated monthly and in real-time batch transactions. MEDS is the central repository for Medi-Cal eligibility data. MEDS records are created and updated in partnership with the statewide county eligibility offices. FAME is used to create a report (See attached CP-0-292) to check against beneficiaries' date of death, which is a temporary solution. The report lists beneficiaries with a date of service past the date of death and the Administrative Services Organization contractor performs claim reversals as needed. DHCS expects to secure access to the SSA's DMF as a permanent solution by February 2021, and share the access with DHCS' contractors via contractual agreements.

Estimated Completion Date: February 2021

California State Auditor's Assessment of Annual Follow-Up Status: Pending

Annual Follow-Up Agency Response From October 2019

DHCS received the Social Security Administration's (SSA) approval for the DMF on August 21, 2019. DHCS is working with SSA to enter into a new agreement to obtain the actual file. DHCS requested to receive the file from SSA on a weekly basis and intends to match it to DHCS' eligibility system using the same frequency. Once DHCS has the file, it will take approximately 90 days to implement the file match with DHCS' eligibility system. Estimated implementation date is unknown as this process is reliant upon SSA. In the interim, DHCS has been collaborating with a data vendor who has access to the DMF and a third party data source to model a quarterly death matching sweep. DHCS received the first matching outputs in June 2019 and is working on the death detection sweep. A second quarterly sweep is expected to commence in October 2019 and ongoing quarterly until SSA can directly share the DMF file with DHCS on a weekly basis.

Estimated Completion Date: Unknown

California State Auditor's Assessment of Annual Follow-Up Status: Pending

Annual Follow-Up Agency Response From November 2018

DHCS continues to receive monthly updates of the DMF, but has not finalized a process to match its eligibility system against these updates. DHCS was recently informed that the DMF is available from the Centers for Medicare and Medicaid Services, and approval is expected by the end of 2018. DHCS anticipates it will begin receiving the DMF file in mid-2019. Once the DMF file is received, DHCS will complete the necessary system changes to utilize the DMF file to match against the Medi-Cal Enrollment Data System (MEDS) and CD-MMIS.

Estimated Completion Date: June 2019

California State Auditor's Assessment of Annual Follow-Up Status: Partially Implemented

Annual Follow-Up Agency Response From September 2017

DHCS issued a letter on January 12, 2017 to all counties reaffirming the instruction to check MEDS alerts for SSN verifications that failed to match. The county must take appropriate steps to verify the accuracy of the SSN should it fail an electronic verification.

Completion Date: January 2017

California State Auditor's Assessment of Annual Follow-Up Status: Partially Implemented

Health Care Services' response does not address obtaining Social Security's Death Master File. When we followed up with Health Care Services' staff, they asserted that Health Care Services now obtains a monthly update of the Death Master File, but it has not yet implemented a process to match its eligibility system against these updates.

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 2016

DHCS-Eligibility Division is actively working towards the implementation of a monthly update from the SSA Death Master File. We believe the audit finding was caused by applicants using fraudulent or erroneous SSNs not the frequency of the death file from SSA. DHCS will issue a policy letter to counties reminding them to follow-up on MEDS alerts when SSNs fail verification. The anticipated completion date of this letter is December 19, 2016.

Estimated Completion Date: December 2016

California State Auditor's Assessment of Annual Follow-Up Status: Not Fully Implemented

1-Year Agency Response

DHCS maintains its forecast that the improvements will be in place on or before April 30, 2016.

Estimated Completion Date: April 2016
Response Date: December 2015

California State Auditor's Assessment of 1-Year Status: Pending

6-Month Agency Response

The Department of Health Care Services (DHCS) is continuing to work on improving the ability to detect unreported beneficiary deaths. Over the last 60 days, DHCS has identified and evaluated numerous federal, state, private, and direct reporting sources. Based on this evaluation, DHCS maintains its forecast that the improvements will be in place on or before April 30, 2016. These improvements include the acquisition, testing, and roll out of new sources and the improvement of existing sources.

Estimated Completion Date: April 2016
Response Date: July 2015

California State Auditor's Assessment of 6-Month Status: Pending

60-Day Agency Response

DHCS intends to increase the frequency of updates to the Medi-Cal Eligibility Data System (MEDS) with the Social Security Administration's Death Master File from quarterly to monthly. The request to increase the frequency to monthly was already in progress and will most likely require an amendment to the existing DHCS/SSA information sharing agreement. The implementation date of April 30, 2016 accounts for the development and testing needed to complete this request.

Estimated Completion Date: April 2016
Response Date: February 2015

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #24 To: Health Care Services, Department of

To ensure that Health Care Services and its fiscal intermediaries reimburse providers only for services rendered to eligible beneficiaries, Health Care Services should coordinate with the appropriate fiscal intermediaries to recover inappropriate payments made for services purportedly rendered to deceased beneficiaries, if necessary.

Annual Follow-Up Agency Response From October 2019

This activity was fully implemented in November 2018 via System Development Notice 15005. Please see attached CP-O-292 and CP-O-007A reports for documentation.

Completion Date: November 2018

California State Auditor's Assessment of Annual Follow-Up Status: Fully Implemented

Annual Follow-Up Agency Response From November 2018

This activity was fully implemented in February 2017 via Systems Development Notice 5005.

Completion Date: February 2017

California State Auditor's Assessment of Annual Follow-Up Status: Partially Implemented

Health Care Services has not provided documentation demonstrating that it adequately reviewed the eligibility for the beneficiaries we identified in our review.

Auditee did not substantiate its claim of full implementation

Annual Follow-Up Agency Response From September 2017

This activity was fully implemented in February 2017 via Systems Development Notice 5005.

Completion Date: February 2017

California State Auditor's Assessment of Annual Follow-Up Status: Pending

Although Health Care Services asserted that it implemented a system change to identify services to deceased beneficiaries, it has not provided adequate documentation supporting its assertion. Further, Health Care Services has not provided documentation demonstrating that it adequately reviewed the eligibility for the 153 beneficiaries identified in our review.

Auditee did not substantiate its claim of full implementation

Annual Follow-Up Agency Response From November 2016

DHCS instructed its fiscal Intermediary, Delta Dental, to identify overpayments and recover these identified overpayments. However, the overpayments did not total to the $70,000 identified by the California State Auditor's (CSA) Office, rather Delta Dental was able to identify seven erroneous claims in the amount of $562.14. In addition, as of April 30, 2016, the Fiscal Intermediary Access to Medi-Cal Eligibility (FAME) file has been developed into a monthly deliverable in CD-MMIS for post-adjudicated claims for services provided after the beneficiary's DOD. As an additional proactive measure, Delta Dental has been tasked with making changes to the CD-MMIS in terms of the review of the monthly post-adjudicated claims for services provided after the beneficiary's DOD through an ad hoc process of post audit findings.

Completion Date: May 2016

California State Auditor's Assessment of Annual Follow-Up Status: Pending

As of March 27, 2017, Health Care Service has not provided documentation demonstrating that it adequately reviewed the eligibility for the 153 beneficiaries identified in our review.

1-Year Agency Response

To validate the identified discrepancies, DHCS performed an in-depth identity verification process on the sample records. For a large number of the records, DHCS discovered data entry errors involving the Social Security Numbers (SSNs). Over 50 records have been corrected to reflect an accurate SSN. DHCS does not anticipate seeking recoveries for those individuals. For the sample records in which DHCS believes dental services were received under a false identity (belonging to a deceased individual), DHCS will evaluate the feasibility of conducting a second EPC to recoup the improper payments.

Additionally, DHCS has taken steps to improve its ability to prevent erroneous payments to providers and managed care plans for services and care that were never provided to the deceased beneficiaries:

-DHCS is actively working with County partners to ensure that they are following all policies and guidance on how to handle the disposition of SSN's that suggest an individual is deceased and actual deceased beneficiary cases and the needed updating of the appropriate eligibility status through MEDS.

-DHCS has obtained access to private data analytic services to identify deceased beneficiaries that do not appear on existing federal/state sources.

DHCS will meet regularly with staff in the Audits and Investigations Division to find ways to improve our death detection systems, report our findings, and prevent erroneous payments.

-DHCS will have Program Review Staff perform on-site County reviews of cases to validate the accuracy of county eligibility decisions and ensure the proper process to update records in MEDS, including those of deceased beneficiaries

Estimated Completion Date: ongoing
Response Date: April 2016

California State Auditor's Assessment of 1-Year Status: Partially Implemented

6-Month Agency Response

DHCS issued an instruction letter to the Fiscal Intermediary to implement a process to recover from providers any identified inappropriate payments made for services purportedly rendered to deceased beneficiaries. This process is dependent on the ability to acquire the Date of Death (DOD) data from the Fiscal Intermediary Access of Medi-Cal Eligibility System. DHCS has also issued an erroneous payment correction to recover payments using stored DOD in the California Dental Medicaid Management Information System (CD-MMIS). The estimated date of completion is April 30, 2016.

Estimated Completion Date: April 2016
Response Date: July 2015

California State Auditor's Assessment of 6-Month Status: Pending

60-Day Agency Response

DHCS will issue an instruction letter to the Fiscal Intermediary to implement a process to recover from providers any identified inappropriate payments made for services purportedly rendered to deceased beneficiaries. This process will be implemented by May 2015.

Estimated Completion Date: May 2015
Response Date: February 2015

California State Auditor's Assessment of 60-Day Status: Pending

All Recommendations in 2013-125

Agency responses received are posted verbatim.