Report 2019-105 Recommendation 3 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 #3 To: Health Care Services, Department of

To increase California's lead testing rates and improve lead test reporting, DHCS should, by no later than June 2020, incorporate into its contracts with managed care plans a requirement for the plans to identify each month all children with no record of receiving a required test and remind the responsible health care providers of the requirement to test the children. DHCS should also develop and implement a procedure to hold plans accountable for meeting this requirement.

Annual Follow-Up Agency Response From October 2021

DHCS continues to maintain the position that quarterly notifications are sufficient and align with the spirit and intent of CSA's recommendation. Further, at this time the California Department of Public Health (CDPH) does not have the capacity to transmit laboratory screening data to DHCS on a monthly basis, which is needed by the MCPs to ensure an accurate accounting of child members that have received or missed a blood lead test. Additionally, AB 2276 added Section 14197.08 to the Welfare and Institutions Code which requires that MCPs, on a quarterly basis, identify every enrollee who is a child without a record of completing the blood lead screening tests. To remain consistent with AB 2276 as well as APL 20-016, DHCS believes maintaining a quarterly identification process aligns with other supplemental data that DHCS provides to MCPs. Further, the quarterly identification requirement is also included in the CY 2021 Base Contract Amendment that DHCS has submitted to CMS. DHCS agrees that timely notification and accountability are critical to early intervention. Therefore, DHCS intends to add formal reporting of the LSC measure to its MCAS. MCAS MCPs that do not take steps to ensure blood lead screenings are completed timely in order to meet the MCAS standards will be subject to a CAP and/or sanctioned. As mentioned earlier, to assist MCPs with accurately identifying children who have not received a blood lead screening, DHCS has begun transmitting laboratory blood lead test data from the CDPH Blood Lead Screening Registry on a quarterly basis. This data, combined with DHCS' blood lead claims and encounter data, is distributed to each MCP and provides them with data files that aid in most accurately identifying which child members have received a screening and which child members may be missing the test so that MCPs and Providers can conduct appropriate outreach.

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

DHCS describes several reasons for its assertion that quarterly notifications are sufficient; however, it has not demonstrated whether its quarterly notifications have sufficiently improved testing rates. Until it demonstrates that the quarterly notifications have had the intended effect, we stand by our recommendation to send monthly notices to communicate the importance of providing lead tests and encourage providers to proactively provide these tests. Because children at the ages of one and two are especially vulnerable to the effects of lead, and testing delays can result in increased damage for those children with elevated lead levels, it is vital that children with elevated lead levels are identified as soon as possible and that steps are taken to prevent further exposure.

1-Year Agency Response

The contract amendment was submitted to CMS in December 2020. The contract submission includes a requirement for MCPs to identify each quarter all children with no record receiving a required lead test, and remind the health care provider of the requirement to test children. As documented in the previous response, requiring a monthly notification process is not feasible because after an initial notice is sent to a provider, the provider needs time to outreach, schedule, and provide services before another notice is sent to the provider for the same enrollee. In addition, providers may not immediately submit encounter/claims data to contracted health plans, possibly resulting in plans unnecessarily noticing providers for services already rendered. DHCS believes quarterly noticing provides the minimum opportunity for interventions and data submission before follow-up notices are sent.

DHCS released a draft APL for public comment on July 29, 2020, and subsequently issued APL 20-016: Blood Lead Screening of Young Children on September 29, 2020 which established requirements for the MCPs. At the time of APL release, the governor signed AB 2276: "Childhood Lead Poisoning: Screening and Prevention" into law. In order to align with the newly enacted legislation and additional stakeholder feedback, DHCS released a revised version of APL 20-016 on November 2, 2020. The revised APL added the authority of DHCS to implement procedures and sanctions as well as some clarifications for age range and voluntary refusal requirements. DHCS will begin reviewing health plan policies and procedures within 90 days after APL 20-016 release to ensure MCP compliance with the policy. DHCS will also review the MCP process related to the contractual requirement during the annual medical audit, and impose a CAP if non-compliance is identified. Since the DHCS annual medical audit is a one-year retrospective audit, DHCS will begin auditing the policy in 2021.

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

DHCS provided documentation to substantiate the actions it indicated it has taken; however, those actions are not completely aligned with our recommendation. Specifically, DHCS has required managed care plans to provide notices on a quarterly basis rather than a monthly basis, as we recommended. Although DHCS stated that it is not feasible to provide these notices on a monthly basis, we question the accuracy of this statement. DHCS has not presented any information regarding why it is not feasible to provide these notices; rather, it's comments address the feasibility of physicians providing and reporting the missing tests. However, even if it is not feasible for physicians to provide and report such tests within one month, sending additional notices will communicate the importance of providing these tests and encourage providers to proactively provide lead tests when they are due to avoid receiving notices in the first place.

Children at the ages of one and two are especially vulnerable to the effects of lead, and testing delays can result in increased damage for those children with elevated lead levels. Thus, it is important that children with elevated lead levels are identified as soon as possible and that steps are taken to prevent further exposure. If a one year old child is not tested after receiving the first two quarterly notices, they will be closer in age to their second required test than the first. Therefore, we stand by our recommendation that DHCS require monthly notices.

6-Month Agency Response

Due to the pandemic's impact on DHCS workload, the submission of the contract amendment to CMS for approval is targeted to be submitted by August 2020. The contract submission will include a requirement for MCPs to identify each quarter all children with no record of receiving a required lead test, and remind the responsible health care provider of the requirement to test children. As documented in the previous response, requiring a monthly notification process is not feasible because after an initial notice is sent to a provider, the provider needs time to outreach, schedule, and provide services before another notice, for the same enrollee, is sent to the provider. In addition, providers may not immediately submit encounter/claims data to contracted health plans, possibly resulting in plans unnecessarily noticing providers for services already rendered. DHCS believes quarterly noticing provides the minimum opportunity for interventions and data submission before follow-up notices are sent.

Also due to the pandemic's impact on DHCS workload, DHCS plans to release a draft APL for public comment no later than July 2020, and issue the final APL in the 3rd Quarter of 2020, establishing the MCP policy. DHCS will review health plan policies and procedures to ensure MCP compliance with the policy. DHCS will also review the MCP process related to the contractual requirement during the annual medical audit, and impose a CAP if non-compliance is identified. Since the DHCS annual medical audit is a one-year retrospective audit, DHCS will begin auditing the policy in 2021.

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

We look forward to reviewing DHCS' implementation of this recommendation upon the completion of the efforts it describes. However, children at the ages of one and two are especially vulnerable to the effects of lead. If they have elevated lead levels it is important that they are identified as soon as possible and that steps are taken to prevent further exposure. With a quarterly notice, a child could be up to 90 days past-due for their required lead test before the MCP sends the first notice and, as DHCS indicates, the provider would still need additional time to outreach, schedule, and provide services to the child. Implementation of this recommendation on a monthly basis could address DHCS' concerns by reinforcing the requirement to provide these tests on time, and encouraging more timely submission of lead test claims to managed care plans. Testing delays can result in increased damage for those children with elevated lead levels. Therefore, we stand by our recommendation that DHCS require monthly notices and our review of its implementation of this recommendation will assess whether the contractual requirement with managed care plans specifies monthly reminders.

60-Day Agency Response

DHCS continues to be on track to submit a contract amendment to CMS for approval by June 2020 that will include a requirement for MCPs to identify each quarter all children with no record of receiving a required lead test and remind the responsible health care provider of the requirement to test the children. It is not feasible to require a monthly notification process because after an initial notice is sent to a provider, the provider needs time to outreach, schedule, and provide services before another notice, for the same enrollee, is sent to the provider. In addition, providers may not immediately submit encounter/claims data to contracted health plans. This may result in plans unnecessarily noticing providers for services already rendered. DHCS believes that quarterly noticing provides the minimum opportunity for interventions and data submission before follow-up notices are sent. Given CMS has a contract review and approval process, DHCS plans to release an All Plan Letter no later than July 2020 establishing the MCP policy. DHCS will review heath plan policies and procedures to ensure MCP compliance with the policy. DHCS will also review the MCP process related to this contractual requirement during its annual medical audit, and impose a CAP if non-compliance is identified. Since the DHCS annual medical audit is a one year retrospective audit, DHCS will begin auditing this policy in July 2021.

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

We look forward to reviewing DHCS' implementation of this recommendation upon the completion of the efforts it describes. However, children at the ages of one and two are especially vulnerable to the effects of lead. If they have elevated lead levels it is important that they are identified as soon as possible and that steps are taken to prevent further exposure. If a quarterly notice is overlooked a child's next test may be shortly due by the time the missed test is provided, resulting in further damage for those children with elevated lead levels. Therefore, we stand by our recommendation that DHCS require monthly notices and our review of its implementation of this recommendation will assess whether the contractual requirement with managed care plans specifies monthly reminders.

All Recommendations in 2019-105

Agency responses received are posted verbatim.