Report 2020-613 Recommendation 4 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 #4 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, resume monitoring pilot program counties' progress in resolving high-risk eligibility alerts.

Rather than resume the MEDS Alerts Pilot Program, which monitored six counties' processing of a limited number of high-risk alerts and did not result in any additional reviews or financial sanctions for continued non-compliance, DHCS will reinstate county performance standards statewide requiring counties to process at least 90 percent of all high-priority MEDS alerts within the timeframes outlined in California WIC section 14154(d)(3) and quickly identifies counties who are not in compliance with the MEDS processing times. 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 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. The new process is anticipated to reduce the number of unprocessed alerts and discrepancies in eligibility status between systems at a far greater rate than the MEDS Alert Pilot.

California State Auditor's Assessment of Status: Will Not Implement

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

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 annual renewals for beneficiaries due for renewal in the month of June 2023, on April 1, 2023. Please see DHCS' Covid-19 PHE Unwind Plan here for comprehensive information regarding the resumption of annual renewals. Included in the Unwind Plan is CMS' guidance supporting state agencies in returning to normal operations through a series of State Health Official (SHO) letters - December 2020, August 2021, and March 2022 and the guidance DHCS has released throughout the PHE. The new implementation date to initiate the activities is June 1, 2024.

California State Auditor's Assessment of Status: Pending

In addition to the previous update, 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.

California State Auditor's Assessment of Status: Pending

DHCS plans to resume all pilot program related activities, including resolution of high-risk eligibility alerts, as of the implementation date 12 months after the termination of the PHE. This will allow counties the opportunity to focus on Centers for Medicare and Medicaid Services (CMS) 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 plans to resume all pilot program related activities, including resolution of high risk eligibility alerts, as of the implementation date, 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 PHE with no modifications to the original plan. DHCS plans to resume all pilot program related activities, including resolution of high risk eligibility alerts, as of the implementation date, which is projected to be 12 months after the end of the PHE.

California State Auditor's Assessment of Status: Pending

No change from the 60-Day update response. DHCS plans to resume all pilot program related activities, including resolution of high risk eligibility alerts, as of the implementation date.

California State Auditor's Assessment of Status: Pending

No change from draft report response. DHCS plans to resume all pilot program related activities, including resolution of high risk eligibility alerts, as of the implementation date.

California State Auditor's Assessment of Status: Pending

All Recommendations in 2020-613

Agency responses received are posted verbatim.