Report 2022-502 All Recommendation Responses

Report 2022-502: Follow-Up: Children in Medi‑Cal: The Department of Health Care Services Is Still Not Doing Enough to Ensure That Children in Medi‑Cal Receive Preventive Health Services (Release Date: September 2022)

Recommendation #1 To: Health Care Services, Department of

To help increase utilization rates, DHCS should begin to monitor and identify effective incentive programs at the health plan level and share the results with all plans.

6-Month Agency Response

The 2022 report was discussed and shared in the October 13, 2022 quarterly CMO Meeting. Attached is the slide deck presentation (Attachment 5) and the final report (Attachment 6) which was shared with the plans. The report illustrates the differences and potential impacts of alternative payment methods offered by the plans during the first two years of data collection. The discussion in the October call highlighted the notable differences and best practices. As noted, the reports for future years will be completed and shared in a similar manner on an annual basis going forward.

DHCS requests CSA deem the recommendation fully implemented. DHCS acknowledges CSA previously provided a perspective on implementation status referencing "a new incentive program in 2023." The Health Equity and Practice Transformation Payments program is under development, but DHCS highlighted the program for information only. The program is not a health plan-established incentive program at the health plan level and is unrelated to the implementation of the recommendation.

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

DHCS identified effective incentive programs at the health plan level and shared the results with all plans.

60-Day Agency Response

There has been no change since the previous implementation plan from the draft report response submitted to CSA on 08/26/22.

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

Although DHCS asserts in its response that it implemented our recommendation in July 2022, the information it shared with the health plans during this time lacked sufficient detail about identified best practices for incentive programs to be useful. Further, as it indicated in its original response to the audit report, DHCS planned to share additional information with the health plans in October 2022 and plans to launch a new incentive program in 2023. Therefore, DHCS's implementation of this recommendation will not occur until sometime in 2023.

Recommendation #2 To: Health Care Services, Department of

To ensure that health plans address underutilization of children's preventive services, DHCS should require plans to use their utilization management programs to identify barriers to usage specifically for these services and hold the plans accountable to address the barriers they identify.

Annual Follow-Up Agency Response From December 2023

The Population Health Management (PHM) program has begun monitoring various Key Performance Indicators (KPIs) assessing utilization of services to include hospitalization admissions, behavioral health services, and primary care access. Additionally, the PHM program has launched a dashboard which tracks KPIs to better determine areas requiring additional improvement efforts to address underutilized services. Page 35 of the CalAIM: Population Health Management (PHM) Policy Guide outlines the monitoring program. Additionally, page 41 identifies how KPIs are attributed to specific populations and page 46 includes more on the framework. The KPIs will be further stratified by age to better monitor Medi-Cal Members under 21 years-of-age. Lastly, DHCS issued quality sanctions for poor performance, which can be found here.

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

DHCS did not provide evidence to substantiate that it had fully implemented this recommendation.

1-Year Agency Response

The Population Health Management (PHM) program has begun monitoring various measures Key Performance Indicators (KPIs) that assess utilization of services to include hospitalization admissions, behavioral health services, and primary care access. Additionally, the PHM program has launched a dashboard that is tracking KPIs to better determine areas that require additional improvement efforts of underutilized services.

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

DHCS did not provide evidence to substantiate that it had fully implemented this recommendation.

6-Month Agency Response

Tracking underutilization data is underway with the Population Health Management requirements and the new contract language. However, the HEDIS rate data is currently undergoing the auditing process. When DHCS receives the rates in July 2023, DHCS will pair the rates with the Population Health Management services and MCP underutilization data to see what quality improvement (QI) efforts can be developed. DHCS is beginning to incorporate underutilization data as a focus for the MCPs which struggle on multiple lower performing measures; DHCS will have the plans take a closer look at this data and develop QI methods to engagement and connect the members to Primary Care Provider.

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

Per DHCS's response, it will not implement this recommendation until July 2023.

60-Day Agency Response

On January 1, 2023, the MCP new contract begins, which requires MCPs to monitor and address underutilization. Also, CalAIM Population Health Management Program launches and requires plans to monitor underutilization of children's services and stratification of data.

In July 2023, DHCS will receive HEDIS results. DHCS will monitor MCP performance rates and track services of children's utilization and delivery. On July 1, 2023, DHCS will begin the focus study with EQRO and assess MCPs methods for addressing barriers resulting in underutilization.

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

Per DHCS's response, it will not implement this recommendation until July 2023.

Recommendation #3 To: Health Care Services, Department of

To better ensure the accuracy of its data and ensure that California receives all available federal Medicaid funding, DHCS should require its External Quality Review Organization (external reviewer) to perform its encounter data validation studies annually using the most recent set of data available, and it should implement recommendations from its external reviewer studies.

Annual Follow-Up Agency Response From December 2023

The EDV report has been published and DHCS will continue to report annually. In response to some of the recommendations in the report, DHCS is directing more efforts into developing more robust monitoring programs to improve data completeness and accuracy; however, DHCS continues to conduct the report with the most recent data.

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

DHCS did not provide evidence to substantiate that it had fully implemented this recommendation.

1-Year Agency Response

The Encounter Data Validation report has been published, and DHCS is now working on developing a more robust monitoring program to assess encounter data and improve data completeness as recommended in the report.

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

DHCS did not provide evidence to substantiate that it had fully implemented this recommendation.

6-Month Agency Response

Full implementation date is extended due to finalization efforts to the Encounter Data Validation report with the EQRO, which is in the final approval processes. Once complete, DHCS will work closely with MCPs to implement the recommendations and monitor improvement.

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

Per DHCS's response, it will not implement this recommendation until June 2023.

60-Day Agency Response

On January 1, 2023, the EQRO will publish EDV results, and DHCS will work with MCPs to implement recommendations and monitor improvement through EDV.

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

Per DHCS's response, it will not implement this recommendation until January 2023.

Recommendation #4 To: Health Care Services, Department of

To mitigate health disparities for children of differing ethnic backgrounds and language needs, DHCS should revise the methodology for its external reviewer's health disparity study to enable it to better make demographic comparisons, and it should use the findings to drive targeted interventions within health plan service areas. It should publish this study annually.

Annual Follow-Up Agency Response From December 2023

The annual Health Disparities Report was published for Measurement Year (MY) 2021 data, and the data report for MY 2022 is under development. Additionally, DHCS received audited, stratified quality measures by race and ethnicity, which will be used for targeted goal setting. MCPs have started disparity-focused clinical performance improvement projects for well-infant visit quality measures. Lastly, DHCS is collaborating and aligning disparity targets across other state programs. The latest Health Disparities Report can be found here. The conclusions and findings of the report are being addressed through the priority areas as laid out in the Comprehensive Quality Strategy report. Additionally, DHCS requires a health equity focused performance improvement project geared toward EQRO report findings, can be found here on page 98.

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

DHCS did not provide evidence to substantiate that it had fully implemented this recommendation.

1-Year Agency Response

The annual Health disparities report was published for MY 2021 data, and the MY 2022 data-based report in under development. Additionally, DHCS received audited stratified quality measures by race/ethnicity, which will be used for targeted goal setting. MCPs have started their disparity focused clinical performance improvement projects for well-infant visit quality measures. Lastly, the DHCS is collaborating and aligning disparity targets across other state programs.

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

DHCS did not provide evidence to substantiate that it had fully implemented this recommendation.

6-Month Agency Response

DHCS is in the final process of completing the health disparities report in collaboration with the EQRO. Additionally, DHCS is actively working across state programs (California Department of Public Health, Department of Managed Health Care, and the California Health and Human Services Agency) in addressing health disparities for targeted measures (immunization, maternal care, and behavioral health); which is currently underway. Additionally, DHCS is working with MCPs on aligning the performance improvement project with a disparity focus for well-infant visits which began in January 2023. DHCS is also in the process of gathering plan calculated HEDIS rates stratified by Race/Ethnicity and should have the rates by July 2023. With the information, DHCS can hold plans accountable to rates with large evident disparity gaps and focus QI on the lower rates. The Estimated Implementation Date has been extended due to efforts of capturing performance measure rates by Race/Ethnicity in July.

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

Per DHCS's response, it will not implement this recommendation until August 2023.

60-Day Agency Response

DHCS continues to update the report and has begun the process of including a more robust demographic analyses spanning broader than racial/ethnicity categorizations and develop targeted approaches to address disparities evident in the report. The upcoming report will include a geographical comparison for DHCS to analyze and make programmatic changes to health equity improvement efforts. Additionally, the upcoming 2021-2022 health disparities reports will include Healthy Places Index (HPI) analysis, which will be used throughout DHCS's QI work and will be de-aggregated down to the plan level so that they can incorporate the information within their strategies to mitigate disparities. DHCS will continue to work with the EQRO incorporating the CSA recommendations for the new Health Disparities Report for 2022-2023, which will include efforts to broaden the racial/ethnic MCP reporting to align with National Committee for Quality Assurance (NCQA) reporting.

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

Per DHCS's response, it will not implement this recommendation until January 2023.

Recommendation #5 To: Health Care Services, Department of

To improve its ability to ensure that children are receiving recommended preventive health services, DHCS should create an action plan to annually address its external reviewer's recommendations relating to children's preventive services, including any recommendations left unaddressed since the external reviewer's fiscal year 2015-16 reports.

1-Year Agency Response

DHCS is tracking External Quality Review Organization recommendations from the Preventive Services Report and addresses how they are or will be achieved and is relayed in the annual publication of the Preventive Services Report. These recommendations are updated annually, and the report is published and presented to external partners.

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

DHCS is tracking recommendations from, and providing updates to, its external reviewer.

6-Month Agency Response

DHCS continues to work with EQRO in implementing recommendations through the various reports. The latest health disparities and Preventive Services Reports should be released in the next few months, and DHCS will be tracking and working through the recommendations. Additionally, DHCS will work to include updates to implementation of recommendations in the following reports.

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

Per DHCS's response, it will not implement this recommendation until July 2023.

60-Day Agency Response

DHCS will continue to work with the EQRO to better assess, improve, and implement recommendations. Additionally, DHCS will create an action plan that better captures EQRO recommendations to include directing quality and health equity improvements MCPs must complete, creating a more stringent accountability process, and better tracking improvements on the recommendations. Currently, DHCS has made efforts with establishing the Affinity group collaboration with Centers for Medicare & Medicaid Services and a few plan partners, and will continue to promote collaborative efforts.

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

Per DHCS's response, it will not implement this recommendation until July 2023.

Recommendation #6 To: Health Care Services, Department of

To ensure that eligible children and their families know about all the preventive services they are entitled to through Medi-Cal, DHCS should include clearer and more comprehensive information about those services in its written materials and ensure annual follow-up with any children and their families who have not used those services.

Annual Follow-Up Agency Response From December 2023

DHCS has made updates to the outreach materials to be in alignment with the Strategy to Support Health and Opportunity for Children and Families. Outreach materials include consumer-friendly brochures explaining the preventive services as well as other services available to all children under Early and Periodic Screening, Diagnostic, & Treatment (EPSDT), and a "Medi-Cal for Kids & Teens: Your Medi-Cal Rights" document which will assist enrolled members in understanding rights to services and the steps to secure services if challenges occur. DHCS took necessary steps to conduct focus testing with both enrolled members and key stakeholders on the member facing materials. Member and stakeholder testing concluded in Q1 of 2023. DHCS released the updated materials on February 14, 2023, to the MCPs and posted the materials on DHCS' public website (https://www.dhcs.ca.gov/services/Medi-Cal-For-Kids-and-Teens/Pages/home.aspx). DHCS directed the MCPs, via All Plan Letter 23-005 on March 16, 2023, to send member-facing materials to members under the age of 21, including any family members, beginning in June 2023 and annually thereafter. In addition, DHCS released provider training materials on February 14, 2023, to the MCPs to ensure providers understand the services covered for children under EPSDT and MCPs' responsibilities to ensure appropriate care. Additionally, DHCS mailed outreach materials directly to members in the Fee-For-Service Program in English and Spanish on August 28, 2023, and all other languages on August 25, 2023 (see Attachment 11 in the Substantiation folder).

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

DHCS completed updates to its outreach materials and requires Managed Care Health Plans to annually inform children and their families of the preventive services to which they are entitled through Medi-Cal.

1-Year Agency Response

DHCS updated the outreach materials to be in alignment with the Strategy to Support Health and Opportunity for Children and Families. Outreach materials and conducted focus testing with both enrolled members and key stakeholders on the member-facing materials by Q1 of 2023. DHCS released the updated materials on February 14, 2023 to the Managed Care Providers (MCP) and posted the materials on DHCS' public website (https://www.dhcs.ca.gov/services/Medi-Cal-For-Kids-and-Teens/Pages/home.aspx). DHCS directed the MCPs, via All Plan Letter 23-005 on March 16, 2023, to send member-facing materials to members under the age of 21, including any family members, beginning in June 2023 and annually thereafter. In addition, DHCS released provider training materials on February 14, 2023 to the MCPs to ensure providers understand the services covered for children under Early and Periodic Screening, Diagnostic and Treatment (EPSDT) and MCPs' responsibilities to ensure appropriate care. Additionally, DHCS mailed outreach materials directly to members in the Fee-For-Service Program in August 2023.

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

DHCS did not provide evidence to substantiate that it had fully implemented this recommendation.

6-Month Agency Response

DHCS has made updates to the outreach materials to be in alignment with the Strategy to Support Health and Opportunity for Children and Families. Outreach materials include consumer-friendly brochures explaining the preventive services as well as other services available to all children under EPSDT, and a "Medi-Cal for Kids & Teens: Your Medi-Cal Rights" document which will assist enrolled beneficiaries in understanding rights to services and the steps to secure services if challenges occur. DHCS took necessary steps to conduct focus testing with both enrolled beneficiaries and key stakeholders on the beneficiary facing materials. Beneficiary and stakeholder testing concluded in Q1 2023. DHCS released the updated materials on February 14, 2023 to the MCPs and public website.

DHCS directed the MCPs, via All Plan Letter 23-005 on March 16, 2023, to send member-facing materials to beneficiaries under the age of 21, including any family members, in Q2 2023 and annually thereafter. In addition, DHCS released provider training materials on February 14, 2023 to the MCPs to ensure providers understand the services covered for children under EPSDT and MCPs' responsibilities to ensure appropriate care. DHCS will send outreach materials directly to beneficiaries in the Fee-For-Service Program. The mailing is scheduled for Q2 of 2023.

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

Per DHCS's response, it will not implement this recommendation until June 2023.

60-Day Agency Response

DHCS has made updates to the outreach materials to be in alignment with the Strategy to Support Health and Opportunity for Children and Families. Outreach materials include consumer-friendly brochures explaining the preventive services as well as other services available to all children under EPSDT, and a "Know Your Rights" document that will assist enrolled beneficiaries in understanding their rights to services and the steps they should to secure services if they encounter challenges. DHCS is currently taking necessary steps to conduct focus testing with both enrolled beneficiaries and key stakeholders on the beneficiary facing materials, as well as a renaming of the term, "EPSDT," to more appropriately resonate with beneficiaries, families, and providers. Beneficiary and stakeholder testing is targeted to begin in Q4 2022. DHCS is still targeting to release the updated materials by the end of Quarter 1 (Q1) 2023 to the MCP. Upon implementation, DHCS will direct the plans, via an All Plan Letter, to send member-facing materials to beneficiaries under the age of 21, including any family members, in Q1 2023 and annually thereafter. In addition, DHCS is developing provider training materials that MCPs will use to ensure providers understand the services covered for children under EPSDT and MCPs' responsibilities to ensure appropriate care. DHCS will send outreach materials directly to beneficiaries in the Fee-For-Service Program. The mailing is scheduled for Q1 of 2023.

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

Per DHCS's response, it will not implement this recommendation until March 2023.

Recommendation #7 To: Health Care Services, Department of

To ensure that health plan provider directories are accurate, DHCS should begin using a 95 percent confidence level and not more than a 10 percent margin of error on its statistical sampling tool and should require at least 95 percent accuracy before approving a health plan's provider directory. In addition, DHCS should ensure that its staff adhere to its policy to retain all documentation related to its review of provider directories for at least three years.

Annual Follow-Up Agency Response From December 2023

DHCS continues its manual process to ensure accuracy of provider directories. Internal conversations are concurrently occurring on how to best utilize the provider directory data obtained by the EQRO to ensure more accurate provider directories. EQRO's current sampling strategy ensures a maximum margin of error of +/- 5 percent and 95 percent confidence level at the provider category level for each reporting unit.

DHCS' Managed Care Contract Oversight Branch implemented a SharePoint Portal in October 2022. Since then, provider directories are received, reviewed, approved, and maintained in the Portal (See Attachment 10 in the Substantiation folder).

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

Per DHCS's response, it will not fully implement this recommendation until July 2024.

1-Year Agency Response

DHCS continues its manual process to ensure accuracy of provider directories Internal conversations are concurrently occurring on how to best utilize the provider directory data obtained by the External Quality Review Organization to ensure more accurate provider directories.

DHCS' Managed Care Contract Oversight Branch implemented a SharePoint Portal in October 2022. Since that date, provider directories have been received, reviewed, approved, and maintained in the Portal.

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

Per DHCS's response, it will not implement this recommendation until July 2024.

6-Month Agency Response

DHCS continues to work with multiple program areas to understand what role can be taken from a data oversight perspective to ensure accuracy of provider directories. EQRO continues validation efforts and DHCS is continuing the manual provider directory review process in tandem while internal conversations occur on how to utilize the EQRO data in the best way to ensure more accurate provider directories.

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

Per DHCS's response, it will not implement this recommendation until September 2023.

60-Day Agency Response

DHCS' EQRO resumed validation in January 2022, and provided two quarters' worth of results to DHCS. MCOD reviewed the data and will be working with other DHCS program areas to discuss MCP correction of identified errors and approval protocols in alignment across DHCS. MCOD met with other DHCS areas the week of October 10, 2022, to begin discussions on how to utilize the EQRO data in the best way to ensure more accurate Provider Directories.

On October 10, 2022, MCOD implemented a SharePoint portal, which will be used as a means for MCPs to submit deliverables (including Provider Directories) for review and approval. Having the SharePoint portal will allow for a repository of all Provider Directories for all MCPs.

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

Per DHCS's response, it will not implement this recommendation until September 2023.

Recommendation #8 To: Health Care Services, Department of

To increase access to preventive health services for children in areas where they are needed most, DHCS should identify where more providers who see children are needed and propose to the Legislature funding increases to recruit more providers in these areas.

1-Year Agency Response

DHCS continues to disagree with the recommendation. DHCS does agree the number of physicians practicing in California would be beneficial for all health care delivery systems. As such DHCS has enacted the CalHealthCares program to increase access to preventive health services for children in areas where they are needed most. Further, in the 2022-2023 state budget, DHCS proposed additional allocation of funding for the program when minimum Medical Loss Ratio is not met by MCPs. The program has focused on supporting providers in under resourced communities.

DHCS anticipates 99 percent of beneficiaries will be enrolled in Medi-Cal MCPs by 2024. DHCS is committed to ensuring MCP networks are sufficient to ensure timely access to care for Medi-Cal members. DHCS has a robust process for reviewing networks, certifying adequacy, and refining processes to improve monitoring of networks and timely access to care. Current monitoring activities include surveying providers to assess compliance with appointment wait time standards; monitoring access to care grievances; and network certifications of MCPs. DHCS continually evaluates the processes to improve our ability to monitor and oversee MCP compliance with network adequacy requirements.

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

Although DHCS asserts that it has taken some steps to ensure that health plans provide timely access to care, without a targeted effort by DHCS to increase the number of Medi-Cal providers in underserved areas, children in Medi-Cal will likely continue to face limited access to care.

6-Month Agency Response

DHCS continues to disagree with the recommendation. DHCS does agree the number of physicians practicing in California would be beneficial for all health care delivery systems. As such DHCS has enacted the CalHealthCares program to increase access to preventive health services for children in areas where they are needed most. Further, in the 2022-2023 state budget, DHCS proposed additional allocation of funding for the program when minimum Medical Loss Ratio is not met by MCPs. The program has focused on supporting providers in under resourced communities.

DHCS anticipates 99 percent of beneficiaries will be enrolled in Medi-Cal MCPs by 2024. DHCS is committed to ensuring MCP networks are sufficient to ensure timely access to care for Medi-Cal members. DHCS has a robust process for reviewing networks, certifying adequacy, and refining processes to improve monitoring of networks and timely access to care. Current monitoring activities include surveying providers to assess compliance with appointment wait time standards; monitoring access to care grievances; and network certifications of MCPs. DHCS continually evaluates the processes to improve our ability to monitor and oversee MCP compliance with network adequacy requirements.

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

Although DHCS asserts that it has taken some steps to ensure that health plans provide timely access to care, without a targeted effort by DHCS to increase the number of Medi-Cal providers in underserved areas, children in Medi-Cal will likely continue to face limited access to care.

60-Day Agency Response

DHCS will not fully implement Recommendation 8. However, DHCS has enacted the CalHealthCares program. Further, in the 2022-2023 state budget, DHCS proposed additional allocation of funding for the program when the minimum MLR is not met by MCPs. The program has focused on supporting providers in under resourced communities.

DHCS anticipates 99 percent of beneficiaries will be enrolled in Medi-Cal MCPs by 2024. DHCS is committed to ensuring MCP networks are sufficient to ensure timely access to care for Medi-Cal members. DHCS has a robust process for reviewing networks, certifying adequacy, and refining the DHCS process to improve monitoring of networks and timely access to care. Current monitoring activities include surveying providers to assess compliance with appointment wait time standards; monitoring access to care grievances; and network certifications of MCPs. DHCS continually evaluates the processes to improve ability to monitor and oversee MCP compliance with network adequacy requirements.

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

Although DHCS asserts that it has taken some steps to ensure that health plans provide timely access to care, without a targeted effort by DHCS to increase the number of Medi-Cal providers in underserved areas, children in Medi-Cal will likely continue to face limited access to care.

All Recommendations in 2022-502

Agency responses received are posted verbatim.