Report 2023-103 All Recommendation Responses

Report 2023-103: The Comprehensive Perinatal Services Program: The Lack of Usage Data Prevents the State From Knowing How Often Medi‑Cal Members Receive Perinatal Care (Release Date: February 2024)

Recommendation for Legislative Action

To ensure the efficient and effective provision of perinatal services throughMedi-Cal, the Legislature should modify state law to assign the primary perinatal
program administration and oversight responsibilities to Health Care Services, and direct Health Care Services to develop a system of oversight to ensure that providers are aware of and offer program services to all pregnant and postpartum Medi-Cal members. As part of this update, the Legislature should consider whether to assign additional data collection duties to Health Care Services, for example by requiring the department to create and use a version of the perinatal services data form mandated by state law. Such a form could track data on perinatal services that would also make possible the department's analysis of utilization rates. To the extent necessary, Health Care Services should then contract with Public Health to maintain any services or program oversight functions best conducted by Public Health.

Recommendation #2 To: Health Care Services, Department of

To ensure effective program oversight and to acknowledge that nearly all Medi-Cal members use managed care plans, Public Health and Health Care Services should, by January 2025, collaborate to update regulations related to the perinatal program. The regulations should include, at a minimum, a clarification of the roles and responsibilities of each department and adjustments to the current monitoring and oversight systems as described individually below to ensure that the departments provide sufficient oversight of the perinatal program.

6-Month Agency Response

Over the past six months, DHCS and CDPH have met monthly to collaborate and identify specific Title 22 changes each department believes are necessary to be responsive to the audit recommendation. Continuing through the end of the year, DHCS and CDPH will collaborate to ensure Medi-Cal members have access to a comprehensive suite of pregnancy and pregnancy-related services and supports, inclusive of those covered under the Comprehensive Perinatal Services Program (CPSP). By January 2025, DHCS and CDPH will identify and finalize the recommended approach for any necessary changes to the Title 22 CPSP regulations and the timing by which the regulation package can be promulgated.

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

60-Day Agency Response

Following the release of the audit and in alignment with the ongoing birthing care pathways work, DHCS and CDPH are actively discussing the future role of Comprehensive Perinatal Services Program (CPSP) as a component part of Medi-Cal's suite of comprehensive pregnancy and pregnancy-related benefits. DHCS and CDPH have regularly scheduled monthly meetings, and the recommendation is a standing agenda item. Over the coming months, DHCS and CDPH will continue to collaborate to ensure Medi-Cal members have access to a comprehensive suite of pregnancy and pregnancy-related services and supports, inclusive of those covered under CPSP. Ultimately, by January 2025, DHCS and CDPH will collaborate to identify any necessary changes to the Title 22 CPSP regulations and the timing by which the regulation package can be promulgated. DHCS and CDPH will continue to provide updates.

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

Recommendation #3 To: Public Health, Department of

To ensure effective program oversight and to acknowledge that nearly all Medi-Cal members use managed care plans, Public Health and Health Care Services should, by January 2025, collaborate to update regulations related to the perinatal program. The regulations should include, at a minimum, a clarification of the roles and responsibilities of each department and adjustments to the current monitoring and oversight systems as described individually below to ensure that the departments provide sufficient oversight of the perinatal program.

6-Month Agency Response

Public Health and Health Care Services have regularly scheduled meetings, and this audit recommendation is a standing agenda item. Public Health and Health Care Services will continue to collaborate to ensure Medi-Cal members have access to a comprehensive suite of pregnancy and pregnancy-related services and support, inclusive of those covered under the Comprehensive Perinatal Services Program (CPSP). Ultimately, by January 2025, Public Health and Health Care Services will collaborate to clarify roles and responsibilities and identify the necessary changes to CPSP-specific statues and regulations and the timing by which the changes can be promulgated.

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

60-Day Agency Response

Health Care Services and Public Health have regularly scheduled monthly meetings and this recommendation will be a standing agenda item. Over the coming months, Health Care Services and Public Health will continue to collaborate to ensure Medi-Cal members have access to perinatal services. By January 2025, Health Care Services and Public Health will collaborate to identify any necessary changes to the California Code of Regulations Title 22 (Comprehensive Perinatal Services' regulations) or other statutes to clarify, at a minimum, respective roles and responsibilities of our departments, and the timing by which such changes can be promulgated. Health Care Services and Public Health will continue to provide updates on this front.

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

Recommendation #4 To: Health Care Services, Department of

To improve its current Medi-Cal monitoring and oversight systems, Health Care Services should do the following:
- Require managed care plans to conduct quality assurance reviews on perinatal service providers, such as OB-GYNs, at least once every three years, beginning by January 2025. If necessary, Health Care Services should seek resources to facilitate this change.
- Include the perinatal program in its risk assessment when determining where to target its annual medical audits.

6-Month Agency Response

Within the past six months, DHCS has expanded the Facility Site Reviews (FSR) and Medical Record Reviews (MRR) (FSR/MRR) to include CPSP services. The revised FSR/MRR tools have been provided to the Medi-Cal Managed Care Plans (MCPs). DHCS continues to work on obtaining and identifying resources to expand site review scope to include obstetrician-gynecologists and other perinatal service providers who offer perinatal services but who are not designated primary care providers.

Additionally, DHCS continues to develop new requirements and guidance for deploying training, certifying additional practitioners, and scheduling site visits to ensure MCP compliance.

DHCS will include the perinatal program in the annual risk assessment by January 2025, for the purposes of targeting annual medical audits.

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

60-Day Agency Response

DHCS continues to work towards the expansion of required Facility Site Reviews (FSR) and Medical Record Reviews (MRR) to include all obstetrician-gynecologist (OB/GYN) providers. Instead of the currently required OB/GYN providers who elect to be primary care providers. DHCS is working towards identifying resources for expanded FSR/MRR scope, which entails issuing Medi-Cal Managed Care Plans (MCPs) guidance, building new requirements into the FSR tool, deploying training, and conducting the onsite reviews. Once resources are identified, staff will work towards expanding DHCS' site review scope, certifying additional practitioners, and scheduling site visits to ensure MCP compliance. Given additional resources, DHCS will revise the FSR scope and issue guidance to MCPs by June 2024, to be effective January 2025. MCPs will need 180 days to secure staffing, schedule additional visits with OB/GYN offices, and begin conducting visits. Additionally, DHCS will include the perinatal program in its annual risk assessment by January 2025.

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

Recommendation #5 To: Health Care Services, Department of

To ensure that the State informs all Medi-Cal members of the perinatal program and the enhanced services available to them, Health Care Services should, by June 2024, update its Medi-Cal template and guidance to managed care plans to require that all member handbooks describe the enhanced perinatal program benefits. At a minimum, this language should include information on pregnancy-related health education, nutrition counseling, and assessments and referrals for basic health needs and mental health care.

6-Month Agency Response

Within the past six months, DHCS and CDPH completed a comprehensive inventory of all member and provider-facing CPSP materials and used the list to guide decision-making in terms of identifying opportunities for both streamlining and enhancement. DHCS and CDPH have identified certain CPSP materials needing refinements. For DHCS, the updates include creating a brand-new maternal health care webpage with a dedicated CPSP subpage with resources for both Medi-Cal members and providers, updates to the "My Medi-Cal" member document (known as PUB 68) to specifically include CPSP material, updates to various sections of the Medi-Cal Provider Manual, and updates to the 2024 MCP Evidence of Coverage (EOC).

Additionally, DHCS would flag a shift in the timing for the release of the "Birthing Care Pathways" public report, which includes CPSP modernization work and is now expected in Quarter 3 of 2024. The report includes input based on engagement with external stakeholders.

The 2024 MCP EOC errata, which includes the perinatal program benefits, has been completed and released to all Medi-Cal MCPs. All MCPs are required to have the 2024 EOC errata containing information on pregnancy-related health education, nutrition counseling, assessments, and referrals for basic health needs and mental health care in production by July 1, 2024.

Beyond the 2024 MCP EOC updates, DHCS expects the new material health/CPSP webpages to be live in Fall 2024, along with the various MCP Manual updates. Lastly, the "My Medi-Cal" (PUB 68) updates are to be completed by March 31, 2025.

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

60-Day Agency Response

DHCS and CDPH have conducted a preliminary inventory of member and provider-facing CPSP materials and intend to use the list to guide decision-making in terms of identifying opportunities for both streamlining and enhancement. DHCS and CDPH recognize certain CPSP materials may benefit from refinements, which will be discussed by DHCS and CDPH at monthly meetings. Additionally, due to the timing of the release of the "Birthing Care Pathways" public report in Summer 2024, as well as the need to engage with external stakeholders, DHCS will continue to provide updates on this front and strive to identify and make any necessary updates to applicable member-facing materials by June 2024.

The 2024 MCP Evidence of Coverage (EOC) is currently being revised via an errata to include the perinatal program benefits identified in Recommendation 3. The updated EOC language that includes updates regarding information on pregnancy-related health education, nutrition counseling, assessments, and referrals for basic health needs and mental health care is undergoing final internal reviews and will be implemented prior to June 2024.

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

Recommendation #6 To: Health Care Services, Department of

To ensure that providers are adequately trained on the requirements of the perinatal program, beginning in January 2025 Health Care Services should require that managed care plans ensure and document that providers have received training as appropriate. At a minimum, this training should include what services are available and how to document that providers offered those services.

6-Month Agency Response

DHCS continues the plan to align any policy work in this space with existing Birthing Care Pathways work. However, as noted in Recommendation 3, the timeline for the release of DHCS' public report has shifted. It is now scheduled to be released in Quarter 3 of 2024. The report will still outline various policy recommendations, including those related to CPSP modernization, and therefore will help inform additional next steps.

In the interim, DHCS, in partnership with CDPH, conducted a comprehensive, internal assessment of all existing Medi-Cal provider-facing materials. This includes policy guidance and training to identify opportunities for making refinements to increase awareness to the comprehensive suite of pregnancy and pregnancy-related services and supports available to Medi-Cal members, including CPSP services to ensure Medi-Cal providers are aware of all policy requirements.

DHCS is in the process of creating a brand-new maternal health care webpage with a dedicated CPSP subpage with resources for both Medi-Cal members and providers. Additionally, DHCS is currently working on updating the CPSP California Medicaid Management Information System provider training relative to all CPSP-related information to ensure it is clear and comprehensive. Additionally, DHCS is continuing to work with CPDH to coordinate CPSP-specific training which compliments DHCS' CPSP billing training, which is estimated to be finalized in Fall 2024.

Lastly, DHCS is still planning to require Medi-Cal MCPs to independently ensure providers have training on the comprehensive suite of pregnancy and pregnancy-related benefits and services covered under Medi-Cal, and training is documented.

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

60-Day Agency Response

DHCS continues the plan to align any policy work in this space with existing Birthing Care Pathways work. DHCS' public report is scheduled to be released in Summer 2024 and will outline various policy recommendations, including those related to CPSP, and therefore help inform the next steps on this front. DHCS will report recommendations and in partnership with CDPH, will conduct an internal assessment of all existing Medi-Cal provider-facing materials, including policy guidance and training, to identify opportunities for making refinements to increase awareness as to the comprehensive suite of pregnancy and pregnancy-related services and supports available to Medi-Cal members, including CPSP services, and ensure Medi-Cal providers are aware of all policy requirements. In addition to DHCS/CDPH's work in this space, DHCS will also require MCPs to independently ensure that providers have training on the comprehensive suite of pregnancy and pregnancy-related benefits and services covered under Medi-Cal, and that training is documented. Additionally, by January 2025, DHCS plans to incorporate a contractual requirement for MCPs to document providers of perinatal services have been trained. DHCS can require the documentation of training by each MCP is submitted to DHCS by June 2025.

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

Recommendation #7 To: Public Health, Department of

By December 2024, Public Health should develop and implement a system to sufficiently verify the survey responses provided by fee-for-service providers. For example, Public Health could conduct chart reviews annually on a selection of fee-for-service providers who have completed its survey to ensure the accuracy of responses. To the extent that such oversight could be provided through a partnership with Health Care Services, Public Health should seek such a collaboration.

6-Month Agency Response

Public Health implemented the first annual CPSP Provider Survey, which was designed for provider oversight purposes.

Public Health is working to maximize survey response rates by actively billing providers, including cross-referencing with administrative data received from Health Care Services.

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

60-Day Agency Response

Public Health will establish procedures for chart reviews to verify a sample of Public Health provider survey responses. Public Health will work with Health Care Services to align with their procedures. Public Health's procedures for chart review may involve identification of provider and beneficiary selection methods to inform an annual request to Health Care Services for perinatal service utilization reports. Public Health will develop and implement a system by December 2024.

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

Recommendation #8 To: Public Health, Department of

To ensure that providers are knowledgeable about the services the perinatal program requires, by December 2024, Public Health should require that all fee-for-service perinatal program providers attend training on administering the perinatal program.

6-Month Agency Response

Public Health and Health Care Services have collaboratively developed an internal inventory for members and providers with CPSP materials, including policy guidance and training, to identify opportunities for both departments to streamline and increase access and awareness to provider trainings of CPSP services.

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

60-Day Agency Response

Public Health's Maternal, Child and Adolescent Health Division will collaborate with our Office of Legal Services to assess the necessity of regulatory changes for mandating provider training. Public Health will work with Health Care Services to align any necessary regulatory changes with Recommendation #3. If regulatory changes are needed, the December 2024 implementation may be delayed, although we will strive to achieve it.

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

Recommendation #9 To: Public Health, Department of

To comply with state law, Public Health should develop and implement a data form for use by providers to collect comprehensive information on perinatal services offered and used, the results of which should be sent to Health Care Services to gather necessary information on the program's usage and effectiveness. At a minimum, this form should include whether providers are rendering perinatal services to Medi-Cal members. Based in part on information collected by local health coordinators during their reviews, we developed a sample form to illustrate the type of information Public Health should collect, as shown in Appendix A.

6-Month Agency Response

Public Health and Health Care Services meet regularly to discuss options for being responsive to the recommendations to capture CPSP program usage and effectiveness. The collaboration supports CPSP modernization across all Medi-Cal systems and will explore current administrative data and tools that exist to help assess program usage and effectiveness.

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

60-Day Agency Response

Public Health will meet with Health Care Services to initiate collaboration on options to capture program usage and effectiveness.

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

All Recommendations in 2023-103

Agency responses received are posted verbatim.