Report 2020-613 Recommendation 3 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 #3 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, expand its workgroup planning efforts to address all high-risk eligibility alerts included in the pilot program.

DHCS will reinstate county performance standards, which require counties to process at least 90 percent of high-priority MEDS alerts within the timeframes outlined in 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 (the workgroup) to develop 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. ACWDL 24-17 outlines the process to identify counties with delays in processing high-priority MEDS alerts, and the actions DHCS will take to ensure counties meet MEDS alerts performance standards. 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.

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 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 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 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 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

Per our previous response, DHCS continues to leverage PHE workgroups to level set expectations of county staff during the continuous coverage unwind. Additionally, DHCS began a quarterly series of MEDS trainings for the counties through the end of the continuous coverage unwind. DHCS published an All County Welfare Directors Letter (ACWDL) 23-14 informing counties to the MEDS Alerts hierarchy. The ACWDL prioritized MEDS alerts which impacts eligibility. Listed in the letter are the MEDS alerts which are monitored in MAP.

CMS confirmed the continuous enrollment requirement is now delinked from the PHE in the Consolidation Appropriations Act of 2023, which ended on March 31, 2023. DHCS began the continuous coverage requirement unwinding activities, including the resumption of renewal activities on April 1, 2023, beginning unwinding annual renewals for the renewal due month of June 2023. The new implementation date is June 1, 2024.

California State Auditor's Assessment of Status: Pending

As indicated in the previous response, DHCS leveraged PHE workgroups to level set expectations of county staff upon the termination of the PHE. Based on these discussions, DHCS issued ACWDL 22-18. This ACWDL provides extensive guidance on case processing actions after the termination of the PHE. Page 10 of the document specifically instructs counties to resolve all high-risk MEDS alerts. DHCS is currently exploring the possibility of providing counties with additional MEDS trainings that focus on resolving high priority MEDS alerts.

CMS has confirmed the continuous enrollment requirement is now delinked from the PHE in the Consolidation Appropriations Act of 2023, (enacted December 29, 2022), which 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.

Link to ACWDL:

https://www.dhcs.ca.gov/services/medi-cal/eligibility/letters/Documents/22-18.pdf

California State Auditor's Assessment of Status: Pending

DHCS leveraged PHE workgroups to level set expectations of county staff upon the termination of the PHE. Based on these discussions, DHCS issued All County Welfare Letter (ACWDL) 22-18. This ACWDL provides extensive guidance on case processing actions after the termination of the PHE. Page 10 of the document specifically instructs counties to resolve all high-risk MEDS alerts.

Link to ACWDL: https://www.dhcs.ca.gov/services/medi-cal/eligibility/letters/Documents/22-18.pdf

California State Auditor's Assessment of Status: Pending

The estimated implementation date was extended by four months and is now September 30, 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

The implementation plan dates were extended seven months due to the extension of the PHE. There has been no change to the implementation plan. DHCS began a cross-divisional workgroup to review all MEDS alerts, and to prioritize MEDS alerts for counties to follow. This will ensure that counties process the most critical alerts accurately and timely. As previously stated, DHCS will ensure the PHE lift workgroup planning efforts incorporate resolution of system discrepancies as a component of the activities counties will perform once the PHE is lifted.

California State Auditor's Assessment of Status: Pending

DHCS began a cross-divisional workgroup review for all MEDS alerts and is working to prioritize MEDS alerts for counties to follow. This will ensure that counties process the most critical alerts accurately and timely. As previously stated, DHCS will ensure the PHE lift workgroup planning efforts incorporate resolution of system discrepancies as a component of the activities counties will perform once the PHE is lifted.

California State Auditor's Assessment of Status: Pending

Through various discussions, DHCS does not believe that the PHE lift workgroup has the participants needed to address the issue. Therefore, high-risk MEDS alerts will be addressed through the MEDS pilot which will be expanded to include all counties in discussions related to MEDS alerts processing upon termination of the PHE.

Due to the anticipated extension of the PHE that may result in updated guidance from the Centers for Medicare and Medicaid Services additional time is needed to complete the process. This resulted in the extension of the estimated implementation date to 04/30/2022.

California State Auditor's Assessment of Status: Pending

No change from draft report response. DHCS will ensure PHE lift workgroup planning efforts incorporate resolution of system discrepancies as a component of the activities counties will perform once the PHE is lifted.

California State Auditor's Assessment of Status: Pending

All Recommendations in 2020-613

Agency responses received are posted verbatim.