Report 2019-105 Recommendation 2 Responses

Report 2019-105: Childhood Lead Levels: Millions of Children in Medi-Cal Have Not Received Required Testing for Lead Poisoning (Release Date: January 2020)

Recommendation #2 To: Health Care Services, Department of

To ensure that families know about the lead testing services that their children are entitled to receive, DHCS should send a reminder to get a lead test for children who missed required tests. It should send this reminder in the required annual notification it is developing to send to families of children who have not used preventive services over the course of a year.

Annual Follow-Up Agency Response From October 2024

DHCS met the implementation date of July 2023, as indicated in the last annual update. Additionally, since the previous 2023 update, DHCS confirmed all MCPs, in response to APL 23-005, updated and submitted for review the policies and procedures (P&Ps), or confirmed requirements were already met and no changes were necessary to demonstrate further compliance. MCPs P&Ps were reviewed and approved by DHCS.

DHCS reviews and, as necessary, makes updates to the Medi-Cal for Kids & Teens materials on an annual basis to ensure alignment with any changes to federal Early Periodic Screening, Diagnosis and Testing (EPSDT) requirements and policy guidance from the Centers for Medicare and Medicaid Services (CMS). The updated 2024 materials were finalized in August 2024 and posted on the DHCS website: Resources | Medi-Cal for Kids & Teens. In addition to posting the EPSDT material on DHCS' website and keeping it current, DHCS also includes this information as part of the myMediCal booklet, which is distributed by counties as part of the new enrollment application packet. The myMedi-Cal also meets the federal CMS 60-day requirement for disseminating these informing materials to all new Medi-Cal members (inclusive of those who enroll in Fee-For-Service (FFS) and those who ultimately enroll in managed care). Lastly, DHCS works with the Office of State Publishing to annually print and mail the EPSDT material to all FFS Medi-Cal members. The last FFS Medi-Cal member mailing occurred in May 2024 for English/Spanish and all other threshold languages in August 2024. DHCS has also already preemptively started work to prepare for the next 2025 annual mailing.

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

DHCS has only partially implemented this recommendation. Its response references the 2023 update and APL 23-005, neither of which included a reminder to get lead tests specifically to the families of children who missed required tests. Similarly, its current response also does not indicate that it is sending notifications specifically to the families of children who missed lead tests. Relying on general information sent to all members is likely less effective at motivating families to get their children tested than directly informing beneficiaries that their child has not received these important tests.

Annual Follow-Up Agency Response From December 2023

DHCS released All Plan Letter (APL) 23-005 on March 16, 2023. The APL details the purpose, background, and policy for coverage of Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services for Medi-Cal Members Under the Age of 21. The APL states MCPs must use the current AAP Bright Futures periodicity schedule and guidelines when delivering care to any Member under the age of 21, including but not limited to health and developmental screening services, physical examination, dental services, vision services, and hearing services. All Members under the age of 21 must receive EPSDT preventative services, including screenings, designed to identify health and developmental issues as early as possible. The APL details MCPs' responsibilities regarding EPSDT in the following areas:

- Behavioral Health Treatment,

- Case Management and Care Coordination,

- Transportation and Member Information, Certain Carved-Out Services,

- California Children's Services Program, Dental Services,

- Outreach and Education Materials, Provider Training, and

- Coordinating with Other Outside Entities Responsible for Providing EPSDT Services.

DHCS worked with the Center for Health Literacy to develop various written member materials for either posting or distribution to members. The materials (referred to as "Medi-Cal for Kids & Teens") included social media and website content, a Know Your Rights letter, and brochures. The materials describe the importance of checkups and screenings, which includes lab tests, including blood lead testing, as a covered service. The materials were finalized in 25 threshold languages and were shared with MCPs on July 3, 2023 and posted on the DHCS website.

Per APL 23-005 MCPs were instructed to:

- Post the materials on the MCP websites and mail the materials for the one-time mailings by no later than July 31, 2023.

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

DHCS' response fails to fully address this recommendation in several respects. First, it asserts that it generated materials for communicating information to Medi-Cal beneficiaries, but instead of sending the communication itself it delegated this task to the managed care plans. In its response it does not describe whether it took action to ensure the managed care plans provided these materials to all relevant beneficiaries. Second, instead of identifying those beneficiaries that have not received a required lead test and informing them or their families of the importance of obtaining such a test, according to DHCS's response the materials it is disseminating are sent to all beneficiaries and describe the services to which they are entitled and the importance of those services. Expecting beneficiaries to determine what services their child has or has not received, instead of informing them that their child has not received an important test, is likely less effective at motivating families to get their children tested. Finally, it is unclear how often this information will be communicated to beneficiaries. The All Plan Letter DHCS sent to managed care plans indicates that they are required to send materials annually, but DHCS's response indicates that this was a one-time mailing, unlike the annual communication that we recommended.

Annual Follow-Up Agency Response From October 2021

Phase 1 of the outreach campaign, which was completed in March 2020, resulted in sending a letter to all eligible Medi-Cal beneficiaries under age 21, not just those that had missed a preventative service such as blood lead screening.

Phase 2 involved working with the CHL to review and assess current preventive care outreach materials, as well as interview stakeholders and survey MCPs on current outreach efforts.

In addition to providing MCP's with outreach materials to use to communicate with their members about preventative services, including blood lead screening, the DHCS has also updated its MCP contracts to require MCP's to identify, at least quarterly, all children with no record of receiving a required lead test, and remind the responsible health care provider of the requirement to test children.

Lastly, in addition to the initial outreach letter, the outbound call campaigns, and updates to the MCP contract, MCPs were also required to submit policies and procedures to DHCS regarding blood lead screening.

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

The letters DHCS sent do not serve as a sufficient reminder to obtain a lead test for those children who missed tests. Specifically, they contain general information, are sent to all beneficiaries, and do not specify whether the child in question has missed a test.

The outreach efforts, MCP contracts, and MCP policies and procedures that DHCS describe are related to health care providers--not the families of children who have missed tests--and thus do not relate to this recommendation.

1-Year Agency Response

DHCS continues to work on a two phase targeted outreach campaign to inform beneficiaries about the availability of, and how to access, American Academy of Pediatrics/Bright Futures services under Medi-Cal. Part of the outreach will include highlighting the availability of lead testing services children are entitled to in Medi-Cal.

DHCS mailed 4,950,510 Preventative Care Outreach Notices in April 2020. Notices were sent to all beneficiaries under the age of 21 with full scope Medi-Cal eligibility. DHCS planned to direct MCPs to conduct a call campaign to follow-up with children and their families who have not used preventive services over the course of a year, including lead testing services for children younger than six years old. The MCP call campaign was scheduled to begin as early as March 2020 for some MCPs.

However, the MCP Outbound Call Campaign was delayed due to the COVID-19 pandemic. The calls were paused in recognition of the State of California's stay-at-home order and state and federal guidance to delay non-essential medical services; to avoid confusion with other communications from public health agencies and MCPs around the pandemic; and to avoid an increase in unscheduled in-person visits to health systems which may be impacted by high volume, stricter infection control procedures, or temporary closures.

After close collaboration with MCPs, DHCS was able to restart the MCP Outbound Call Campaign in November 2020 with modifications which allowed the Plans to not only make outbound calls, but also allowed MCPs to use other modalities for outreach such as member outreach materials, social media platforms, information shared on partnering websites, member portals, and other media. As of the time of this 12 month update, all MCPs have a DHCS approved Preventive Care Outreach proposal and are targeting completing phase I by December 31st, 2020 and phase II by March 31st, 2021 per the required due dates provided by DHCS to the MCPs.

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

The notices DHCS sent do not serve as a sufficient reminder to obtain a lead test for those children who missed tests. Specifically, they contain general information and do not specify whether the child in question has missed a test.

The call campaign DHCS has delegated to the managed care plans may meet the intent of the recommendation; however, DHCS must provide evidence that the calls include a reminder to get a lead test for those children who missed required test, that it has established a procedure to implement the campaign each year, and that it has a documented method to ensure the plans are fulfilling this responsibility.

6-Month Agency Response

DHCS continues to work on a two phase targeted outreach campaign to inform beneficiaries about the availability of, and how to access, American Academy of Pediatrics/Bright Futures services under Medi-Cal. Part of the outreach will include highlighting the availability of lead testing services children in Medi-Cal are entitled to receive.

DHCS completed mailing 4,950,510 Preventative Care Outreach Notices in April 2020. Notices were sent to all beneficiaries under the age of 21 with full scope Medi-Cal eligibility. DHCS had planned to direct MCPs to conduct a call campaign to follow-up with children and the children's families who have not used preventive services over the course of a year, including lead testing services for children younger than six years old. The MCP call campaign was scheduled to begin shortly after the mailing of the outreach notices, as early as March 2020 for some MCPs.

However, the MCP Outbound Call Campaign was delayed due to the COVID-19 pandemic. The calls were paused in recognition of the State of California's stay-at-home order and state and federal guidance to delay non-essential medical services; to avoid confusion with other communications from public health agencies and MCPs around the pandemic; and to avoid an increase in unscheduled in-person visits to health systems which may be impacted by high volume, stricter infection control procedures, or temporary closures. DHCS is closely monitoring the changes in local conditions regarding stay-at-home and other public health guidance, as well as provider reopening and capacity, and is consulting with MCPs and providers regarding local provider readiness and public health conditions to permit the MCP outreach call campaign to begin a narrower, locally appropriate outreach call campaign.

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

DHCS provided a copy of the notice it sent. Although the notice states that "Preventive Care includes things like... lab tests (including blood lead testing)," it does not serve as a reminder to get a lead test for children who missed tests because it does not indicate whether the beneficiary or their child has missed a test. In addition, DHCS did not provide evidence that the notices were sent, or that it has a written policy to conduct this mailing annually.

60-Day Agency Response

DHCS continues to work on a two phase targeted outreach campaign to inform beneficiaries about the availability of AAP/Bright Futures services under Medi-Cal and how to access them. Part of this outreach will include highlighting the availability of lead testing services that children in Medi-Cal are entitled to receive.

DHCS is targeting March of 2020 to mail its first outreach notice to all beneficiaries. This notice will be sent to all beneficiaries under the age of 21 with full scope Medi-Cal eligibility. It will be followed by a call campaign by the MCPs to follow-up with children and their families who have not used preventive services over the course of a year, including lead testing services for children younger than six years old. An evaluation of the existing preventive care outreach materials (with stakeholder and beneficiary involvement) will take place throughout 2020.

Please note the MCP call campaign was scheduled to begin shortly after the mailing of the outreach notices, as early as March 2020 for some MCPs. DHCS has instructed the MCPs to pause or delay initiation of these calls in March and potentially subsequent months, due to the emerging Coronavirus (COVID-19) situation. These calls will be paused to avoid confusion with other communications from public health agencies and MCPs around COVID-19, and to avoid an increase in unscheduled in-person visits to health systems that may be impacted by COVID-19 in the coming weeks, such as hospitals, clinics and physician offices. DHCS is closely monitoring the COVID-19 situation, and will instruct MCPs to begin or resume their call campaigns as soon as it is appropriate given public health and health care system conditions.

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

DHCS is delaying implementation of this recommendation to focus on COVID-19 issues. Upon implementation we will review documentation of DHCS' policy and the notices it has sent.

All Recommendations in 2019-105

Agency responses received are posted verbatim.