Report 2020-613 Recommendation 1 Responses

Report 2020-613: Department of Health Care Services: Despite the COVID-19 Public Health Emergency, the Department Can Do More to Address Chronic Medi‑Cal Eligibility Problems (Release Date: July 2021)

Recommendation #1 To: Health Care Services, Department of

To reduce inappropriate payments made to medical providers and ensure eligible individuals' access to care, Health Care Services should, by August 2021, begin monitoring statewide alerts related to individuals identified as eligible for Medi-Cal in a county eligibility data system but not identified as eligible in the state eligibility system.

DHCS will reinstate county performance standards, which require counties to process at least 90 percent of high-priority Medi-Cal Eligibility Data System (MEDS) alerts within the timeframes outlined in California Welfare and Institution Code (WIC) section 14154(d)(3). Effective June 2024, DHCS transitioned from county self-certification to a data-driven approach, allowing for prompt identification of counties not meeting the required MEDS Alerts processing times. In September 2024, DHCS collaborated with the County Welfare Director's Association, the California Statewide Welfare Automated System, and county health and human services agencies to develop the All County Welfare Director's Letter (ACWDL) 24-17 detailing the new county performance standards policy, how DHCS will monitor compliance, confirm suspected non-compliance, the actions taken when a county fails to process MEDS alerts on time, and the financial penalties for not meeting the standards which were published on November 26, 2024. DHCS issued ACWDL 23-14E, which provides counties with a prioritized hierarchy of MEDS Alerts subject to the MEDS county performance standards on October 23, 2024. Monitoring the alerts state-wide will reduce the number of individuals identified as eligible for Medi-Cal in the California Automated Welfare System, but not identified as eligible in MEDS.

California State Auditor's Assessment of Status: Fully Implemented

No change from the response originally provided to CSA on 07/08/2024.

DHCS has begun the process of resuming the Medi-Cal Eligibility Data System (MEDS) Alert Pilot monitoring of high-priority MEDS alerts effective June 1, 2024, with plans to expand and integrate the pilot into its regular oversight activities by the end of December 2024. In preparation, DHCS released the All County Welfare Directors Letter (ACWDL) 23-14, which assists counties with prioritizing MEDS alerts and serves as advance notice of the alerts DHCS will incorporate into its MEDS monitoring activities.

California State Auditor's Assessment of Status: Pending

DHCS has begun the process of resuming the Medi-Cal Eligibility Data System (MEDS) Alert Pilot monitoring of high-priority MEDS alerts effective June 1, 2024, with plans to expand and integrate the pilot into its regular oversight activities by the end of 2024. In preparation, DHCS released the All County Welfare Directors Letter (ACWDL) 23-14, which assists counties with prioritizing MEDS alerts and serves as advance notice of the alerts DHCS will incorporate into its MEDS monitoring activities.

California State Auditor's Assessment of Status: Pending

DHCS continues to monitor counties regularly through the Medi-Cal Eligibility Database Systems (MEDS) Alert Pilot (MAP) reports. DHCS also published MEDS Alert Hierarchy policy letter ACWDL 23-14, providing counties guidance on what alerts impact eligibility and share of cost. DHCS will commence monitoring the alerts identified in ACWDL 23-14 on June 1, 2024. The new implementation date of June 1, 2024, aligns with the end of DHCS' eligibility and unwinding activities.

California State Auditor's Assessment of Status: Pending

In addition to the previous update, the Centers for Medicare and Medicaid Services (CMS) has confirmed the continuous enrollment requirement is now delinked from the PHE in the Consolidation Appropriations Act of 2023, (enacted December 29, 2022), and the continuous enrollment requirement ended on March 31, 2023. DHCS began the continuous coverage requirement unwinding activities, including the resumption of renewals, on April 1, 2023. The new implementation date to initiate these activities is May 1, 2024.

California State Auditor's Assessment of Status: Pending

In the effort to begin monitoring these statewide alerts, DHCS will alert counties regularly through the MEDS Alert Pilot (MAP) reports. Covering the largest counties, these MAP reports will incorporate Medi-Cal Eligibility Database Systems (MEDS) alerts that indicate eligibility in Statewide Automated Welfare Systems (SAWS) but not in MEDS. Incorporating these alerts into the permanent, statewide MEDS Alert monitoring process is part of the California Advancing and Innovating Medi-Cal (CalAIM) county oversight and monitoring proposal, to be launched 12 months after the termination of the Public Health Emergency (PHE). This will allow counties the opportunity to focus on Centers for Medicare and Medicaid mandated PHE unwinding activities.

12 months after the termination of the PHE, DHCS will move forward with the original implementation plan as listed above and on the 30-day update.

California State Auditor's Assessment of Status: Pending

The estimated implementation date was extended by four months and is now November 1, 2023, due to an extension of the PHE for COVID-19. The dates of implementation are dependent on the termination date of the PHE. Therefore, when the PHE termination date is extended, the dates must be recalculated based on the new termination date. Depending on the recommendation, the implementation plan cannot begin until a certain number of months after the PHE ends.

Otherwise, no change from the previous response, which was the 12-month program update submitted to CSA on July 12, 2022.

California State Auditor's Assessment of Status: No Action Taken

DHCS plans to move forward with the implementation plan provided in the previous update upon termination of the PHE with no modifications to the original plan. DHCS is working to incorporate Medi-Cal Eligibility Database Systems (MEDS) Alert number 6016, an alert that indicates eligibility in Statewide Automated Welfare Systems (SAWS) but not in MEDS, into the MEDS Alert Pilot (MAP) reports DHCS sends to counties on a regular basis. MAP consists of the largest counties in the state; therefore, MAP is sufficient to begin initial monitoring of the alert through the pilot. DHCS will incorporate alert number 6016 into a permanent, statewide MEDS Alert monitoring process as part of the California Advancing and Innovating Medi-Cal (CalAIM) county oversight and monitoring proposal effective July 1, 2023, or one year after the termination of the PHE.

California State Auditor's Assessment of Status: Pending

DHCS plans to move forward with the implementation plan provided in the previous update upon termination of the public health emergency (PHE) with no modifications to the original plan. DHCS is working to incorporate Medi-Cal Eligibility Database Systems (MEDS) Alert number 6016, an alert which indicates eligibility in Statewide Automated Welfare Systems (SAWS) but not in MEDS, into the MEDS Alert Pilot (MAP) reports DHCS sends to counties on a regular basis. MAP consists of the largest counties in the state; therefore, MAP is sufficient to begin initial monitoring of the alert through the pilot. DHCS will incorporate alert number 6016 into a permanent, statewide MEDS Alert monitoring process as part of the California Advancing and Innovating Medi-Cal (CalAIM) county oversight and monitoring proposal effective July 1, 2023, or one year after the termination of the PHE.

California State Auditor's Assessment of Status: Pending

No change from the 60-Day update response. DHCS is working to incorporate Medi-Cal Eligibility Database Systems (MEDS) Alert number 6016, an alert which indicates eligibility in Statewide Automated Welfare Systems (SAWS) but not in MEDS, into the MEDS Alert Pilot (MAP) reports DHCS sends to counties on a regular basis. MAP consists of the largest counties in the state; therefore, MAP is sufficient to begin initial monitoring of the alert through the pilot. DHCS will incorporate alert number 6016 into a permanent, statewide MEDS Alert monitoring process as part of the California Advancing and Innovating Medi-Cal (CalAIM) county oversight and monitoring proposal no later than December 31, 2022.

California State Auditor's Assessment of Status: Pending

No change from the draft report response. DHCS is working to incorporate MEDS Alert number 6016, an alert which indicates eligibility in SAWS but not in MEDS, into the MAP reports DHCS sends to counties on a regular basis. MAP consists of the largest counties in the state; therefore, MAP is sufficient to begin initial monitoring of the alert through the pilot. DHCS will incorporate alert number 6016 into a permanent, statewide MEDS Alert monitoring process as part of the CalAIM county oversight and monitoring proposal no later than December 31, 2022.

California State Auditor's Assessment of Status: Pending

All Recommendations in 2020-613

Agency responses received are posted verbatim.