Report 2018-111 Recommendation 8 Responses

Report 2018-111: Department of Health Care Services: Millions of Children in Medi-Cal Are Not Receiving Preventive Health Services (Release Date: March 2019)

Recommendation #8 To: Health Care Services, Department of

To ensure that eligible children and their families know about all the preventive services they are entitled to through Medi-Cal, DHCS should include by May 2019 clearer and more comprehensive information about those services in its written materials and by September 2019 ensure annual follow-up with any children and their families who have not used those services.

Annual Follow-Up Agency Response From September 2022

There is no agency response for this update. Government Code section 8546.1(d) authorizes the California State Auditor to conduct follow-up audit work on statutorily mandated or legislatively required financial and performance audits. Our office followed up on this March 2019 audit to assess DHCS's status regarding implementation of the eight outstanding recommendations from this report. Below is our assessment of the status of this recommendation based on work we performed during the follow-up audit. All future updates for this recommendation will be posted under the follow-up audit (2022-502).

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

Although DHCS hired a contractor to develop written materials about children's preventive services—such as brochures, mailing notices, and content that it can post on its website and social media pages—DHCS chose not to publish the materials because they no longer align with DHCS's new communication strategy for children in Medi-Cal. DHCS stated that it will continue to work with key stakeholders to develop new materials and, to the extent feasible, will leverage portions of the original materials that are still applicable. DHCS hopes to make available the new materials by March 2023.

Annual Follow-Up Agency Response From October 2021

DHCS worked with the Center for Health Literacy (CHL) to make extensive edits to the 2022 Evidence of Coverage - Member Handbook to incorporate more robust language regarding the EPSDT benefit. The Member Handbook describes the EPSDT benefit as designed to assure that children receive early detection and care, so that health problems are averted or diagnosed and treated as early as possible. EPSDT was expanded throughout the Member Handbook to various sections including Covered Services, Behavioral Health Treatment, Child and Youth Well Care and the Words to Know definition section. In addition a text box specific to EPSDT was also added to the Member Handbook to emphasize the importance of EPSDT as a medical necessary service. The Member Handbook also describes Covered Services as free.

Also, as part of the Preventive Care Outreach project, DHCS worked with the CHL to review and assess current preventive care outreach materials, as well as interview stakeholders and survey MCPs on current outreach efforts. Using the results of this analysis, CHL created new key messaging and outreach materials including an outreach letter, brochure, website content and social media campaigns all focused on encouraging accessing preventive services including EPSDT. These materials were tested with a sampling of beneficiaries in five languages. The work with CHL concluded on June 30, 2021 and DHCS was provided with the final materials and templates. DHCS is working on next steps for both DHCS and the MCPs to begin using the newly developed outreach materials which would include a letter that reminds beneficiaries about the availability of preventive care services, including blood lead screening.

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

Full implementation of this recommendation requires DHCS to provide information about the benefits of preventive health care and that those services are free to eligible individuals and are available upon request, including information about the benefits of preventive health care and the costs of those services. It will also require targeted reminders specifically to families of children who have not used preventive services in the past year. These are not steps DHCS has yet taken.

Annual Follow-Up Agency Response From November 2020

DHCS disagrees regarding the updated Member Handbook language not being adequate, but will commit to reviewing the language and making any necessary updates in the upcoming 2021 Member Handbook template if additional language is determined to be needed.

DHCS has continued implementation of Phase 1 of the Preventive Care Outreach project, and launched the phase of the outreach requiring MCPs to perform targeted outreach via an outbound call campaign. Outreach messaging must reflect notifying beneficiaries of preventive care services not received or not received for an extended period. Due to the ongoing impacts of the COVID 19 pandemic on primary care providers, DHCS has extended the timeframe for calls to be completed as well as allowed plans to use alternate and/or a combination of modalities to perform the required outreach. Outreach campaigns targeting children under age six are expected to be completed no later than June 2021.

Phase 2 of the Preventive Care Outreach project involves researching current preventive care materials and engaging stakeholders, beneficiaries, and health plans to provide feedback on existing materials and outreach efforts. New materials will be created and distributed based on the outcomes of the research. Due to the COVID-19 pandemic, Phase 2 was delayed; however, stakeholder and advocate engagement is scheduled to begin in September 2020. Phase 2 is expected to be completed by June 30, 2021.

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

Full implementation of this recommendation will require DHCS to provide information about the benefits of preventive health care and that those services are free to eligible individuals and are available upon request, including information about the benefits of preventive health care and the costs of those services, in addition to ensuring annual follow-up with children and their families who have not used those services.

1-Year Agency Response

The finalized member handbook updates, with feedback that DHCS received, was provided to plans on July 19, 2019. All approvals by DHCS were completed by September 3, 2019. Currently, all plans are mailing the member handbook update with the revised preventive services language.

The Preventive Care Outreach project will be divided into two phases:

- Phase 1 of the Preventive Care Outreach project directs DHCS to use targeted outreach (via mail and a call campaign) to inform beneficiaries under 21 with full scope Medi-Cal eligibility about the EPSDT services available and how to access services.

On October 1, 2019, DHCS provided a draft outreach notice to plans and other stakeholders for feedback. The extensive stakeholder engagement process included written feedback, a follow-up call with key advocate groups, and the sharing of the notice with incorporated feedback. DHCS will begin mailing the notice on February 28, 2020, to approximately five million Medi-Cal beneficiaries under the age of 21.

Call campaigns, approved by DHCS, will be conducted by the MCPs to beneficiaries under the age of 21. The call campaigns will include notifying beneficiaries of preventive care services they have not received or have not received for an extended period of time.

- Phase 2 of the Preventive Care Outreach project will involve DHCS contracting with an independent entity, Maximus, to conduct surveys of beneficiaries, design outreach materials, and engage with stakeholders in order to determine the best outreach process moving forward. Phase 2 is expected to be completed by December 31, 2020.

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

The finalized member handbook template that DHCS provided does not address all of the concerns we raise on page 30 of our report. Federal law requires DHCS to provide information about the benefits of preventive health care and that those services are free to eligible individuals and are available upon request. However, the updated handbook continues to include information that is incomplete, such as insufficient information about the benefits of preventive health care and the costs of those services.

6-Month Agency Response

DHCS finalized the language regarding the EPSDT benefit that will be used in the MCP Member Handbook/EOC. The language includes more comprehensive information about beneficiary entitlements under the EPSDT benefit. DHCS provided out to Plans on July 1, 2019, to be used as an errata in their current 2019 Member Handbook. Additional feedback was received by the Plans after it was provided and therefore DHCS is currently making updates. Plans will be expected to have their Plan specific errata approved by DHCS two weeks from the time that the final version of the errata is provided. Plans will be expected to begin mailing the errata with their Member Handbooks immediately after DHCS approval.

DHCS is working internally on the targeted outreach campaign to inform beneficiaries about the availability of the AAP/Bright Futures services under Medi-Cal and how to access them. This outreach will include a process to specifically follow-up with children and their families who have not used preventive services over the course of a year. A timeline for stakeholder engagement is forthcoming.

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

60-Day Agency Response

DHCS has shared and collected feedback from MCPs, stakeholders, and advocates on draft language regarding the EPSDT benefit that will be used in the MCP Member Handbook/EOC. The language includes more comprehensive information about beneficiary entitlements under the EPSDT benefit. DHCS is on track to finalize the EOC which will include the updated EPSDT language by July 1, 2019.

DHCS is working internally on the targeted outreach campaign to inform beneficiaries about the availability of the American Academy of Pediatrics (AAP)/Bright Futures services under Medi-Cal and how to access them. Stakeholder engagement is forthcoming.

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

We look forward to reviewing clearer and more comprehensive language about the preventive services children and their families are entitled to in DHCS' updated member handbook and Evidence of Coverage in its 6-month response. We expect DHCS' outreach campaign to include a procedure to specifically follow-up with children and their families who have not used preventive services over the course of a year.

All Recommendations in 2018-111

Agency responses received are posted verbatim.