Report 2023-115 All Recommendation Responses

Report 2023-115: Department of Health Care Services and Department of Managed Health Care: Children Enrolled in Medi-Cal Face Challenges in Accessing Behavioral Health Care (Release Date: November 2023)

Recommendation #1 To: Health Care Services, Department of

To better ensure appropriate and effective monitoring of timely access to behavioral health care for children, by November 2024 DHCS should make changes to its survey methodologies to do the following, and then implement those changes for the subsequent reporting period: Use its timely access surveys to monitor compliance with the 48 hour urgent appointment standard established in state law where applicable.

60-Day Agency Response

The Department of Health Care Services (DHCS) updated the External Quality Review Organization (EQRO) Timely Access scope of work for the 2024 reporting year to reflect the addition of the two-day urgent appointment. The change will be reflected in the 2024 EQRO Technical Report, which will be published by April 30, 2025.

As part of the methodology adjustment, DHCS will explore implementing monitoring for both new and existing patients. The adjustment will significantly impact the EQRO's scope of work pertaining to the timely access survey. DHCS will need to secure additional funding for the EQRO to change the survey approach, updating all call scripts and methodology, and work to test the updated methodology. Assuming funding is secured, and scope can be expanded DHCS will implement the change no later than the 2025 EQRO Technical Report, which is published by April 30, 2026.

DHCS also updated the EQRO scope of work for the 2024 reporting year to disclose the proportion of providers excluded from the survey, the reasons for exclusion, and impact on the survey results. The results will be part of the 2024 EQRO Technical Report, which will be published by April 30, 2025.

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

DHCS has updated the scope of work with its EQRO for the 2023-24 timely access study to include the 48-hour standard for certain urgent appointments. We will review its reporting of compliance with the standard when it publishes its 2024 report in 2025.

Recommendation #2 To: Health Care Services, Department of

To better ensure appropriate and effective monitoring of timely access to behavioral health care for children, by November 2024 DHCS should make changes to its survey methodologies to do the following, and then implement those changes for the subsequent reporting period: Disclose the proportion of providers excluded from its survey results for each plan, the reasons for excluding those providers, and how such exclusions may affect the survey's conclusions about access to care.

60-Day Agency Response

The Department of Health Care Services (DHCS) updated the External Quality Review Organization (EQRO) Timely Access scope of work for the 2024 reporting year to reflect the addition of the two-day urgent appointment. The change will be reflected in the 2024 EQRO Technical Report, which will be published by April 30, 2025.

As part of the methodology adjustment, DHCS will explore implementing monitoring for both new and existing patients. The adjustment will significantly impact the EQRO's scope of work pertaining to the timely access survey. DHCS will need to secure additional funding for the EQRO to change the survey approach, updating all call scripts and methodology, and work to test the updated methodology. Assuming funding is secured, and scope can be expanded DHCS will implement the change no later than the 2025 EQRO Technical Report, which is published by April 30, 2026.

DHCS also updated the EQRO scope of work for the 2024 reporting year to disclose the proportion of providers excluded from the survey, the reasons for exclusion, and impact on the survey results. The results will be part of the 2024 EQRO Technical Report, which will be published by April 30, 2025.

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

Recommendation #3 To: Health Care Services, Department of

To better ensure appropriate and effective monitoring of timely access to behavioral health care for children, by November 2024 DHCS should make changes to its survey methodologies to do the following, and then implement those changes for the subsequent reporting period: Use its timely access surveys to monitor compliance with the timely appointment standards for both new and existing patients.

60-Day Agency Response

The Department of Health Care Services (DHCS) updated the External Quality Review Organization (EQRO) Timely Access scope of work for the 2024 reporting year to reflect the addition of the two-day urgent appointment. The change will be reflected in the 2024 EQRO Technical Report, which will be published by April 30, 2025.

As part of the methodology adjustment, DHCS will explore implementing monitoring for both new and existing patients. The adjustment will significantly impact the EQRO's scope of work pertaining to the timely access survey. DHCS will need to secure additional funding for the EQRO to change the survey approach, updating all call scripts and methodology, and work to test the updated methodology. Assuming funding is secured, and scope can be expanded DHCS will implement the change no later than the 2025 EQRO Technical Report, which is published by April 30, 2026.

DHCS also updated the EQRO scope of work for the 2024 reporting year to disclose the proportion of providers excluded from the survey, the reasons for exclusion, and impact on the survey results. The results will be part of the 2024 EQRO Technical Report, which will be published by April 30, 2025.

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

Recommendation #4 To: Managed Health Care, Department of

To better ensure appropriate and effective monitoring of timely access to behavioral health care for children, by November 2024 Managed Health Care should make changes to its survey methodologies to do the following, and then implement those changes for the subsequent reporting period: Use its timely access surveys to monitor compliance with the 48 hour urgent appointment standard established in state law where applicable.

60-Day Agency Response

The Department of Managed Health Care's (DMHC) Measurement Year (MY) 2022 Timely Access Report will include new charts and appendices setting forth the mean and median average appointment wait time for each required product, in accordance with Section 1367.03, sub. (f)(3). To implement this recommendation, both the new charts and appendices will include the 48 hour and 96 hour urgent appointment standards to allow the DMHC and members of the public to easily evaluate compliance with both urgent appointment wait time standards across the industry, by product, and by health plan.

The DMHC believes this recommendation will be fully implemented upon publication of the MY 2022 Timely Access Report in early 2024; however, the DMHC will continue to assess ways to incorporate this standard into rate of compliance calculations for specialist physicians and non-physician mental health providers. If the CSA does not agree that this recommendation is fully implemented, the DMHC will need additional staffing and statistical funding, as well as an extension to the APA exemption set forth in Section 1367.03, sub. (f)(3) to implement and refine changes to the survey methodology.

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

Although Managed Health Care's upcoming report states that the standards for urgent appointments can be 48 or 96 hours, depending on whether prior authorization is required, it still combines the data on available urgent appointments. This makes it unclear whether the data is for the next available appointment that falls under the 48-hour standard or not. Full implementation of the recommendation will require more clarity that the surveys are asking about and recording appointments specifically for appointment types that fall under the 48-hour standard.

Recommendation #5 To: Managed Health Care, Department of

To better ensure appropriate and effective monitoring of timely access to behavioral health care for children, by November 2024 Managed Health Care should make changes to its survey methodologies to do the following, and then implement those changes for the subsequent reporting period: Disclose the proportion of providers excluded from its survey results for each plan, the reasons for excluding those providers, and how such exclusions may affect the survey's conclusions about access to care.

60-Day Agency Response

The DMHC will need additional resources to fully implement the CSA's recommendations. This includes producing dashboards or data tables that will enhance the DMHC's ability to present health plan-level ineligible and non-response data in the future. Therefore, the DMHC will not fully implement CSA's recommendation.

However, to be responsive to the CSA's recommendations within DMHC's current resources, the DMHC's MY 2022 Timely Access Report will include both industry level ineligible and non-responsive provider data and set forth how the exclusion of these providers from the survey results may affect the rates of compliance. While the health plan-reported number and percentage of ineligible and non-responsive providers is included in the survey results data, annually published on DMHC's public website, the MY 2022 Timely Access Report does not include health plan-level analysis due to resource limitations, the large volume of data (over 1.7 million records of data) and limited time to publish the report.

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

The department has indicated that it will not implement this recommendation.

Recommendation #6 To: Managed Health Care, Department of

To better ensure appropriate and effective monitoring of timely access to behavioral health care for children, by November 2024 Managed Health Care should make changes to its survey methodologies to do the following, and then implement those changes for the subsequent reporting period: Use its timely access surveys to monitor compliance with the timely appointment standards for both new and existing patients.

60-Day Agency Response

The DMHC will need additional staffing and statistical funding to develop and test changes to the methodology, and annually evaluate and report the results in the Timely Access Report. The DMHC's methodology is codified into regulation. Any change to the methodology requires regulatory amendment. The DMHC's current exemption from the Administrative Procedures Act (APA) only allows the DMHC to make changes until December 31, 2025. Typically, development and testing of significant changes to the statistical methodology require several years to complete. After the initial implementation, the DMHC and its statistical vendor evaluate the data reported under the updated methodology and make additional refinements to ensure that the resulting data is valid and reliable. Where significant changes are made, such as those recommended by the CSA, refinements may be required over several reporting cycles. As of this date, any changes would be included in the next methodology for measurement year 2025, and the resulting data would be reported to the DMHC on May 1, 2026. Given the expiration of the APA exemption in H&S section 1367.03, sub. (f)(3) on December 31, 2025, the DMHC will need an extension of the APA exemption to implement and refine these changes in future regulatory amendments to the survey methodology.

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

Managed Health Care's response indicates that it will not implement this recommendation.

Recommendation #7 To: Health Care Services, Department of

To assess opportunities to help ensure unbiased timely access survey data, by November 2024, DHCS should determine the feasibility, costs, and likely benefits of adopting a "secret shopper" approach to its timely access surveys. If the department determines that adopting such an approach is reasonably feasible and beneficial, it should implement this methodology by the next reporting year.

60-Day Agency Response

DHCS is continuing to evaluate the feasibility of adopting a "secret shopper" approach to the timely access surveys for the Medi-Cal managed care plans (MCPs).

As part of the feasibility analysis, DHCS will need to consider the operational steps needed when adjusting the methodology, which includes securing additional funding for the EQRO to change the survey approach, working with the EQRO to test the new methodology, and providing guidance to implement the new process with MCPs.

If the approach is determined feasible, DHCS will implement the adjusted methodology by the reporting year 2026 for the Medi-Cal Managed Care delivery system.

DHCS intends to pilot the secret shopper process in the reporting year 2025 for Drug Medi-Cal Organized Delivery System (DMC-ODS) and Specialty Mental Health Services (SMHS) providers.

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

Recommendation #8 To: Managed Health Care, Department of

To assess opportunities to help ensure unbiased timely access survey data, by November 2024, Managed Health Care should determine the feasibility, costs, and likely benefits of adopting a "secret shopper" approach to its timely access surveys. If the department determines that adopting such an approach is reasonably feasible and beneficial, it should implement this methodology by the next reporting year.

60-Day Agency Response

The DMHC has significant concerns regarding the feasibility and utility of a secret shopper survey. In addition, the DMHC would need consulting funding to conduct an independent evaluation of the feasibility, costs, and benefits of adopting a "secret shopper" survey. A secret shopper survey would not allow for collection of mental health follow-up appointment wait times, because it can only assess appointment wait times for new patients and cannot measure access for existing patients. (Nor would it allow the DMHC to implement Recommendation 3.) Further, it would not allow for meaningful measurement of specialist physicians and ancillary provider appointment wait times, because these providers often require a referral from a physician and/or prior authorization prior to scheduling an appointment. While a secret shopper survey is unlikely to adequately capture these appointment types, all three classes of appointment wait times are required to be measured by H&S section 1367.03, sub. (f)(3). Given these and other concerns, the DMHC may explore other options to address the potential bias concerns.

Based on the DMHC's five years of experience in developing a survey methodology and the complexities involved with a secret shopper survey, it is estimated to take four to five years to successfully develop and implement this recommendation. Thus, the DMHC cannot implement a secret shopper survey prior to the expiration of the APA exemption on December 31, 2025. (H&S section 1367.03, sub. (f)(3).) In addition to an extension of this APA exemption, the DMHC would also need additional staffing and statistical funding to implement this change.

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

Managed Health Care indicates that it will not implement this recommendation.

Recommendation #9 To: Health Care Services, Department of

To improve its ability to use timely access surveys as a tool to improve access to behavioral health services, by November 2024, DHCS should develop a compliance threshold for the percentage of appointments in each Medi-Cal managed care plan meeting timely access standards. For example, DHCS might consider how many calls a member should have to make before obtaining a timely appointment and calculate a threshold accordingly.

60-Day Agency Response

DHCS has initiated conversations with the Department of Managed Health Care to develop consistent compliance thresholds. Once established, DHCS will set compliance thresholds and inform the MCPs of the policy by November 2024.

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

Recommendation #10 To: Health Care Services, Department of

To help determine whether timely access to mental health services for children is improving, by November 2024, DHCS should report in each year's timely access survey results on the extent to which those results are comparable to previous years' results and, where data is comparable, discuss the extent to which timely access to care is improving or declining.

60-Day Agency Response

For non-specialty mental health, DHCS updated the 2024 EQRO scope of work to include the year-over-year trending methodology. DHCS will work with the EQRO to trend Timely Access Survey data starting with the 2023 and 2024 survey results. The findings will be published as part of the 2024 EQRO Technical Report, which will be published by April 30, 2025.

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

Recommendation #11 To: Health Care Services, Department of

To improve Medi-Cal members' access to behavioral health services from county mental health plans and Drug Medi-Cal programs, by November 2024, DHCS should demonstrate that it has followed up with county mental health plans and Drug Medi-Cal programs on CAPs that continue to be deficient in timely access or other network adequacy standards. In doing so, it should assess whether the plans took the actions described in their CAPs and, if so, why those actions did not result in sufficient improvement.

60-Day Agency Response

Prior to the audit, DHCS had identified steps to improve the Corrective Action Plan (CAP) process for county Mental Health Plans (MHPs) and DMC-ODS plans, collectively referred to as Behavioral Health Plans (BHPs). For the FY 2023-24 network adequacy certification period, BHPs began submitting Annual Network Adequacy Certification documentation on November 1, 2023. DHCS is currently processing the information. BHPs found out-of-compliance with network adequacy standards will be required to submit a CAP along with applicable supporting documentation. BHPs that remain out-of-compliance will be contacted and required to attend a technical assistance call(s) required to address the reasons why the BHP remains non-compliant. Additionally, for data-driven network adequacy standards, the BHP will be required to submit the applicable data to DHCS monthly to show compliance. DHCS will conduct the appropriate analysis and provide results to the BHP. For non-data-related deficiencies that remain non-compliant, DHCS will establish a monitoring timeline to provide periodic check-ins with the BHP to ensure the applicable required documentation needed to bring the BHP into compliance is submitted and reviewed. If BHPs fail to demonstrate sufficient progress or improvement via this process, DHCS will issue financial sanctions when deemed appropriate. Additionally, Drug Medi-Cal (DMC) counties submitted timely access data on November 1, 2023, in response to the implementation of the Mental Health Parity and Addiction Equity Act of 2008. DHCS published BHIN 22-070 on December 30, 2022, which requires DMC counties to meet timely access requirements as specified in 28 CCR 1300.67.2.2 (c)(5). FY 2023-24 is the inaugural year; thus, results will be advisory. Beginning FY 2024-25, DMC counties will be held to compliance, and any DMC county found out of compliance will follow the CAP process as described above.

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

DHCS provided the Information Notice it created outlining its expectations of BHPs on CAPs, and indicating it will follow up with BHPs on CAPs that continue to be deficient in timely access or other network adequacy standards. We will assess whether DHCS fully implements this recommendation by conducting that follow-up and making determinations of causes for continued deficiencies after it fully processes the information BHPs submitted in November 2023, and after it begins conducting the same analysis for DMCs beginning in fiscal year 2024-25.

Recommendation #12 To: Health Care Services, Department of

To ensure that children in Medi-Cal have timely access to behavioral health services from county mental health plans and Drug Medi-Cal programs, by November 2024, DHCS should analyze county mental health plans' and Drug Medi-Cal programs' appointment data according to age group to determine if each county meets the compliance threshold for timely access for both adults and children. To the extent a plan does not meet timely access standards for either group, DHCS should require corrective action.

Recommendation #13 To: Health Care Services, Department of

To ensure that Medi-Cal managed care plans have a sufficient number of providers to offer timely access and meet children's behavioral health care needs, by May 2024, DHCS should develop a new methodology for calculating non-specialty outpatient behavioral health provider-to-member ratios. At minimum, the methodology should consider the following factors:
-The expected demand for behavioral health services by children in Medi-Cal, based on factors including but not limited to past services.
-The estimated number of children likely to need those services.
-The number of full-time providers needed to provide that volume of services.
-The amount of time individual providers spend treating Medi-Cal members.
The methodology should also accommodate potential growth in the need for behavioral health services.

60-Day Agency Response

By May 2024, DHCS will conduct an analysis to consider the above-recommended factors and update the provider-to-member ratio methodology accordingly. DHCS is planning the analysis and has begun research into studies to address mental health provider-to-member ratios. In developing an updated methodology, DHCS will consider the feasibility of each of the recommended factors based on available data.

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

Recommendation #14 To: Health Care Services, Department of

When determining the number of mental health providers a managed care plan has available to serve children in Medi-Cal, DHCS should consider whether providers serve multiple plans or multiple regions within a single plan. When providers do so, DHCS should account for that overlap, such as by reducing the expected contribution of a provider to a given plan when that provider serves multiple plans or regions within a plan.

60-Day Agency Response

DHCS has initiated a work effort to update the non-specialty outpatient behavioral health provider-to-member ratios methodology as part of improvements to the annual network certification (ANC) process. The updated methodology will add a full-time equivalent (FTE) analysis within each MCPs network and will be included in the 2024 ANC. DHCS will initiate a work effort in 2024 to assess the feasibility of adjusting the FTE analysis to account for providers who are contracted with more than one MCP. If feasible, DHCS intends to roll out as part of ANC 2026.

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

Recommendation #15 To: Health Care Services, Department of

To ensure that Medi-Cal managed care plan members do not have to travel unreasonable times or distances to receive care, DHCS should develop a definition of what times and distances are reasonable for members to travel. In doing so, DHCS should consider both the total time or distance a member needs to travel, as well as how those times and distances compare to other plans' times and distances for the same provider type and ZIP code. Thereafter, when DHCS determines that plans' requests for alternative time and distance standards are not reasonable, it should not approve those alternative access standards, thereby requiring those plans to offer members out-of-network access until such time as the plans can provide reasonable travel times and distances to care.

60-Day Agency Response

DHCS has begun analysis and is working on a project plan and approach to determine reasonability. To the extent possible, the policy will be aligned across managed care delivery systems and can be adopted for specialty behavioral health as well.

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

Recommendation #16 To: Health Care Services, Department of

To ensure that Medi-Cal managed care plans make efforts to obtain additional providers to meet network adequacy standards, by May 2024, DHCS should revise its agreements with plans that do not meet time and distance standards to require them to demonstrate efforts to recruit new providers to underserved areas.

60-Day Agency Response

DHCS acknowledges an increase in the behavioral health care workforce, including physicians who practice in California and are enrolled in Medi-Cal would be beneficial. DHCS contractually requires MCPs to ensure and monitor an appropriate provider network within service areas in compliance with network adequacy standards, and if necessary, attempt to contract with providers in adjoining counties outside the service area. To strengthen further, no sooner than the contract year 2025, DHCS will contractually require MCPs that do not comply with specified network adequacy requirements to demonstrate efforts in recruiting new providers in underserved areas. The same contract requirements and considerations apply to specialty behavioral health plans. DHCS has begun MCP contract language development efforts to effectuate the provider recruitment requirements.

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

Recommendation #17 To: Health Care Services, Department of

To more effectively encourage plans to comply with network adequacy standards, by May 2024, DHCS should develop and implement a policy outlining when noncompliance with network adequacy standards by a Medi-Cal managed care plan, county mental health plan, or county Drug Medi-Cal program justifies financial penalties.

60-Day Agency Response

DHCS collaborates internally regarding MCP performance concerns and builds a consensus on the appropriate enforcement actions across program areas. DHCS discussed the policy in November 2023 and began the development of the policy. DHCS will implement the policy by May 2024.

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

Recommendation #18 To: Managed Health Care, Department of

To identify and address timely access issues that affect children, by November 2024, Managed Health Care should update its survey methodology to assess compliance with timely access standards specifically for behavioral health care providers serving children.

60-Day Agency Response

To be responsive to the CSA's recommendations, the DMHC will need additional staffing and statistical funding to develop and test changes to the methodology, and annually evaluate and report the results in the Timely Access Report. As indicated in response to recommendation 3, the DMHC's methodology is codified into regulation. Any change to the methodology requires regulatory amendment. The DMHC's current exemption from the Administrative Procedures Act (APA) only allows the DMHC to make changes until December 31, 2025. Typically, development and testing of significant changes to the statistical methodology require several years to complete. After the initial implementation, the DMHC and its statistical vendor evaluate the data reported under the updated methodology and make additional refinements to ensure that the resulting data is valid and reliable. Where significant changes are made, such as those recommended by the CSA, refinements may be required over several reporting cycles. As of this date, any changes would be included in the next methodology for measurement year 2025, and the resulting data would be reported to the DMHC on May 1, 2026. Given, given the expiration of the APA exemption in H&S section 1367.03, sub. (f)(3) on December 31, 2025, the DMHC will need an extension of the APA exemption to implement and refine these changes in future regulatory amendments to the survey methodology.

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

Managed Health Care's response indicates it will not implement this recommendation.

All Recommendations in 2023-115

Agency responses received are posted verbatim.