Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services, including Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services for any individual under 21 years of age who is covered under Medi-Cal consistent with the requirements under federal law. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Under existing law, one of the methods by which Medi-Cal services are provided is pursuant to contracts with various types of managed care plans, and existing law requires the department to pay capitation rates to the managed care plans.

Existing federal law provides that EPSDT services include periodic screening services, vision services, dental services, hearing services, and other necessary services to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not the services are covered under the state plan.

This bill would require, consistent with federal law, that screening services provided as an EPSDT benefit include developmental screening services for individuals zero to 3 years of age, inclusive, and would require Medi-Cal managed care plans to ensure that providers who contract with these plans render those services in conformity with specified standards. The bill would require the department to ensure a Medi-Cal managed care plans ability and readiness to perform these developmental screening services, and to adjust a Medi-Cal managed care plans capitation rate. Until July 1, 2023, the bill would require an external quality review organization (EQRO) entity to annually review, survey, and report on managed care plan reporting and compliance with specified developmental screening tools and schedules. review and report annually on Medi-Cal managed care plan metrics for developmental screenings, and would require the department to use the EQROs technical report to monitor Medi-Cal managed care plans compliance with providing enrollees access to developmental screenings. The bill would also make legislative findings and declarations relating to child development.

CONCURRENCE IN SENATE AMENDMENTS

CSA1 Bill Id:AB 1004

Author:(McCarty)

As Amended Ver:August 30, 2019

Majority vote

SUMMARY:

Requires, consistent with federal law, screening services provided as an Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Medi-Cal benefit to include developmental screening services for individuals zero to three years of age. Requires Medi-Cal Managed Care (MCMC) plans to ensure and monitor compliance with developmental screening services provided by providers who contract with MCMC plans to ensure compliance with the periodicity schedule and the standardized and validated developmental screening tools established by the Bright Futures Guidelines and Recommendations for Preventive Pediatric Health Care (Bright Futures), as established by the American Academy of Pediatrics (AAP), and developmental screening tools are administered by contracted providers in their entirety and in adherence to, the specific tools' recommended guidelines. Requires, until July 1, 2023, as part of the federally required external quality review organization (EQRO) review of MCMC plans, the EQRO entity to review and report annually on MCMC plan metrics for development screenings included in the federal Centers for Medicare and Medicaid Services Core Set of Children's Health Care measures (CMS Core Set) for Medicaid and Children's Health Insurance Program. Requires the Department of Health Care Services (DHCS) to use the EQRO's technical report to monitor MCMC plans' compliance with providing enrollees access to developmental screenings. Requires DHCS to ensure that MCMC plans demonstrate ongoing ability and readiness to perform the monitoring of developmental screening in this bill. Requires DHCS, as may be appropriate and in its discretion, to adjust the capitation rate of a MCMC plan to promote improved outcomes through value-based purchasing payment protocols to create improved incentives for outcomes.

The Senate Amendments:

Prohibit the EPSDT requirements in this bill from limiting or restricting blood screening requirements under existing law, change the EQRO review of MCMC plan performance from the AAP periodicity schedule to the CMS Core Set, and require DHCS to use the EQRO's technical report to monitor MCMC plans' compliance with providing enrollees access to developmental screenings.

COMMENTS:

Focused study on development screening. In 2016, DHCS contracted with its EQRO to conduct a focused study to help DHCS determine if Common Procedural Terminology (CPT) Code 96110 (CPT Code 96110 is a code for developmental screening) could be used to evaluate plans' rates for the "Developmental Screening in the First Three Years of Life" measure in California as DHCS considered the potential inclusion of this measure in its External Accountability Set. Of the 23 plans that received the questionnaire, the EQRO received 20 distinct responses, with two plans not responding and two plans submitting a combined response due to their contractual setup. In reporting the results, DHCS indicated statewide coding rate for CPT 96110 at 1, 2, and 3 years of age was 54.8%, 41.1%, and 30.8 respectively, with a total over three years of 36.4%. DHCS indicated the questionnaires identified similar barriers, including lack of education on the importance of children receiving development screening (provider and beneficiary), resource constrains, lack of referral services and/or pathways, inconsistent use of standardized tools, inconsistent use of CPT 96110, and data reporting issues so that it cannot be accurately assessed whether or not a child has received developmental screening.

According to the Author:

Research has shown that earlier screenings make a positive impact on our youngest learners. Early identification and intervention can improve a child's long-term outcome, and minimize the need for costly health care, special education, juvenile justice, and child welfare services down the road. This bill will also ensure that developmental screenings, which are shown to be very effective, are routinely occurring for infants and toddlers during Medi-Cal health care visits.

Arguments in Support:

This bill is jointly sponsored by Children Now and First 5 LA, which argue that by establishing clear guidelines and oversight for developmental screenings for children ages 0-3 years old, delays will be identified earlier and California's children will be more likely to achieve their greatest potential. Currently, California ranks just 43rd in the nation for parents completing timely developmental screenings. First 5 LA states the AAP established Bright Futures guidelines for developmental screenings nearly 20 years ago, but pediatricians still often rely on surveillance alone, rather than a validated screening tool, to identify children at risk for developmental delays. Overall, just 37% of California pediatricians indicate that they use a validated or evidence-based screening tool to identify the majority of developmental concerns. This lack of consistency in practice has kept California as one of the lowest-performing states for developmental screening. First 5 LA states that 70% of children with delays go undetected until kindergarten, which creates additional demands for California's special education system and puts California children at a serious disadvantage.

Arguments in Opposition:

The Department of Finance writes in opposition that this bill because it is duplicative of recent actions by DHCS and investments included in the 2019 Budget Act. DOF argues the Medi-Cal State Plan already requires providers to screen all children for developmental delays through EPSDT and in accordance with the Bright Futures guidelines and recommendations. DOF states DHCS is also in the process of adding the CMS adult and child core set reporting to the EQRO's annual evaluation of managed care plans, and this core set includes a quality metric for developmental screening in the first three years of life and will be combined with an increase in the minimum performance level for managed care plans. Finally, DOF writes that the 2019 Budget Act includes $53.9 million ($23.1 million Proposition 56 and $30.8 million federal funds) for new incentive payments for developmental screening services.

FISCAL COMMENTS:

According to the Senate Appropriations Committee, staff estimates low-hundreds of thousands for the EQRO entity to review and report metrics for developmental screenings costs. Contracting funds would be funded by 25% General Fund/75% federal funds. Staff notes unknown potentially high-tens of thousands, for DHCS administrative workload to review the EQRO's technical report to monitor MCMC plans' compliance. To the extent DHCS utilizes the EQRO's technical report as part of existing compliance monitoring, staff notes costs could be negligible but are unknown at this time.

VOTES:

ASM HEALTH: 15-0-0

YES: Wood, Mayes, Aguiar-Curry, Bigelow, Bonta, Burke, Wicks, Flora, Limón, McCarty, Nazarian, Ramos, Rodriguez, Santiago, Waldron

ASM APPROPRIATIONS: 18-0-0

YES: Gonzalez, Bigelow, Bloom, Bonta, Brough, Calderon, Carrillo, Chau, Diep, Eggman, Fong, Gabriel, Eduardo Garcia, Maienschein, Obernolte, Petrie-Norris, Quirk, Robert Rivas

ASSEMBLY FLOOR: 78-0-2

YES: Aguiar-Curry, Arambula, Bauer-Kahan, Berman, Bigelow, Bloom, Boerner Horvath, Bonta, Brough, Burke, Calderon, Carrillo, Cervantes, Chau, Chen, Chiu, Choi, Chu, Cooper, Cunningham, Dahle, Daly, Diep, Eggman, Flora, Fong, Frazier, Friedman, Gabriel, Gallagher, Cristina Garcia, Gipson, Gloria, Gonzalez, Gray, Grayson, Holden, Irwin, Jones-Sawyer, Kalra, Kamlager-Dove, Kiley, Lackey, Levine, Limón, Low, Maienschein, Mathis, Mayes, McCarty, Medina, Melendez, Mullin, Muratsuchi, Nazarian, O'Donnell, Obernolte, Patterson, Petrie‑Norris, Quirk, Quirk-Silva, Ramos, Reyes, Luz Rivas, Robert Rivas, Rodriguez, Blanca Rubio, Salas, Santiago, Smith, Mark Stone, Ting, Voepel, Waldron, Weber, Wicks, Wood, Rendon

ABS, ABST OR NV: Cooley, Eduardo Garcia

SENATE FLOOR: 40-0-0

YES: Allen, Archuleta, Atkins, Bates, Beall, Borgeas, Bradford, Caballero, Chang, Dahle, Dodd, Durazo, Galgiani, Glazer, Lena Gonzalez, Grove, Hertzberg, Hill, Hueso, Hurtado, Jackson, Jones, Leyva, McGuire, Mitchell, Monning, Moorlach, Morrell, Nielsen, Pan, Portantino, Roth, Rubio, Skinner, Stern, Stone, Umberg, Wieckowski, Wiener, Wilk

UPDATED:

VERSION: August 30, 2019

CONSULTANT: Scott Bain / HEALTH / (916) 319-2097 FN: 0001949

 THIRD READING  

Bill No: AB 1004

Author: McCarty (D), et al.

Amended: 8/30/19 in Senate

Vote: 21

SENATE HEALTH COMMITTEE: 8-0, 7/3/19

AYES: Pan, Stone, Lena Gonzalez, Hurtado, Leyva, Mitchell, Monning, Rubio

NO VOTE RECORDED: Grove

SENATE APPROPRIATIONS COMMITTEE: 7-0, 8/30/19

AYES: Portantino, Bates, Bradford, Durazo, Hill, Jones, Wieckowski

ASSEMBLY FLOOR: 78-0, 5/23/19 - See last page for vote

SUBJECT: Developmental screening services

SOURCE: Children Now

First 5 LA

DIGEST:

This bill requires early and periodic screening, diagnostic, and treatment screening services to include developmental screening services for Medi-Cal beneficiaries ages zero to three, inclusive. Requires Medi-Cal managed care plans to ensure contracted providers administering developmental screenings comply with the Bright Futures Guidelines and Recommendations for Preventive Pediatric Health Care established by the American Academy of Pediatrics. Requires the external quality review organization, beginning on July 1, 2020, to annually review and report on Medi-Cal managed care plans’ compliance with providing enrollees access to developmental screenings.

ANALYSIS: Existing federal law requires early and periodic screening, diagnostic, and treatment (EPSDT) services to include screening, vision, dental, hearing and other Medicaid health care, diagnostic services, treatment, and other measures to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services. [42 USC §1396d]

Existing state law:

1. Establishes the Medi-Cal program, which is administered by the Department of Health Care Services (DHCS) and under which qualified low-income individuals receive health care services. [WIC §14000, et seq.]
2. Establishes a schedule of benefits in the Medi-Cal program, which includes the EPSDT program for any individual under 21 years of age, consistent with the specified requirements federal Medicaid law. [WIC §14132]
3. Requires the “medically necessity” standard, for purposes of services available to individuals under 21 years of age through the EPSDT program, to mirror the standards established in existing federal regulations. [WIC §14059.5]
4. Requires DHCS to convene an advisory group to update the protocols and tools for screening children for trauma within the EPSDT program. Requires the working group to consider existing screening tools, including but not limited to, the Staying Healthy Assessment developed by the department, the United States Preventive Services Task Force grade “A” or “B” recommendations, and the American Academy of Pediatrics (AAP) Recommendations for Preventive Pediatric Health Care periodicity schedule and guidance. [WIC §14132.19]
5. Requires DHCS to convene a steering committee to provide advice and recommendations on the development of the Medi-Cal mental health managed care system and the delivery of services, including services provided to children through EPSDT. [WIC §14682.1]
6. Requires DHCS to require county MHPs to include a process for screening, referring, and coordinating services for eligible Medi-Cal beneficiaries, including coordination with education programs and any other necessary services for children, consistent with existing law. [WIC §14683]

This bill:

1. Requires EPSDT screening services to include developmental screening services for Medi-Cal beneficiaries ages zero to three, inclusive.
2. Requires Medi-Cal managed care plans to ensure and monitor compliance with the following:
   1. Developmental screening services provided by providers who contract with Medi-Cal managed care plans comply with the periodicity schedule and the standardized and validated developmental screening tools that are established by the AAP Bright Futures Guidelines, and by any future updates to this material; and,
   2. Developmental screening tools are administered by providers who contract with Medi-Cal managed care plans in their entirety, and in adherence to, the specific tools’ recommended guidelines.
3. Prohibits this bill from limiting or restricting the scope of the EPSDT benefits for eligible Medi-Cal beneficiaries, pursuant to existing law.
4. Requires the external quality review organization (EQRO), beginning on or after July 1, 2020, to annually review and report on Medi-Cal managed care plan metrics for developmental screenings included in the federal Centers for Medicare and Medicaid Services’ (CMS) Core Set of Children’s Health Care Quality Measures for Medicaid and Children’s Health Insurance Program. Requires DHCS to use the EQRO technical report to monitor Medi-Cal managed care compliance with providing enrollees access to developmental screenings. Sunsets this provision on July 1, 2023.
5. Authorizes DHCS to adjust the capitation rate of a Medi-Cal managed care plan to promote improved outcomes through value-based purchasing.

Comments

1. Author’s statement. According to the author, research has shown that earlier screenings make a positive impact on our youngest learners. Early identification and intervention can improve a child’s long-term outcome, and minimize the need for costly health care, special education, juvenile justice, and child welfare services down the road. This bill will also ensure that developmental screenings, which are shown to be very effective, are routinely occurring for infants and toddlers during Medi-Cal health care visits
2. EPSDT. EPSDT is a federally mandated benefit available to all Medi-Cal eligible individuals under the age of 21. Under EPSDT, Medi-Cal is required to provide comprehensive services and cover all medically necessary services needed to correct and ameliorate health conditions, including any medical, dental, vision, hearing, or mental health needs. The screening services must include a number of check-ups, including:
   1. Comprehensive health and developmental history;
   2. Physical exam;
   3. Appropriate immunizations;
   4. Laboratory tests;
   5. Health education;
   6. Vision services;
   7. Dental services;
   8. Hearing services, and,
   9. Other necessary health care services found to be medically necessary to treat, correct or reduce illnesses and conditions discovered regardless of whether the service is covered in the Medicaid State Plan.

According to Georgetown University Health Policy Institute, the last category includes terms with important nuances. First, the service must be considered medically necessary. A determination of whether a service is medically necessary must be made on a case-by-case basis, taking into account a particular child’s needs. Practically, this means that states may not impose hard limits on pediatric services because the service could be medically necessary for some children. States may impose tentative limits on services pending an individualized determination, a decision shared by the state and the child’s treating provider. Second, the service must be provided regardless of whether it is covered under the State Plan, the agreement between the state and the federal government describing how a state will administer its Medicaid program. This means that Medi-Cal may provide services under the EPSDT program that may not be available to other Medi-Cal enrollees. When a screening indicates a need for further evaluation, EPSDT covers diagnostic services and ultimately any services necessary to treat the identified health problems.

1. Bright Futures. According to DHCS, the Affordable Care Act (ACA) specified that coverage of preventive care and screenings must be conducted with evidence-informed, comprehensive guidelines supported by the Health Resources and Services Administration (HRSA), which is an agency of the U.S. Department of Health and Human Services. The HRSA participated in the development of, and provides ongoing support to, the national health promotion and prevention initiative known as Bright Futures, which is led by the AAP. The AAP develops theory-based and evidence-based driven guidance and recommendations for preventive care screenings and well-child visits for children and regularly publishes updated tools and resources for use by clinicians and state agencies. These tools include the “Bright Futures Guidelines” and the “Recommendations for Preventive Pediatric Health Care,” which is also known as the “periodicity schedule”. The ACA mandates the use of the Bright Futures periodicity schedule and guidelines when delivering the EPSDT benefit.

The Child Health and Disability Prevention Program (CHDP) is responsible for the screening component of the EPSDT benefit of the Medi-Cal program. CHDP issues guidelines to set CHDP provider standards for pediatric health assessments for children served by the CHDP Program. DHCS indicates these guidelines are consistent with the AAP Bright Futures Guidelines and the MCP contracts require MCP to provide all age-specific assessments consistent with Bright Futures.

1. State Auditor report findings. In March 2019, the State Auditor released an audit report on DHCS’s oversight of the delivery of preventive services to children in Medi-Cal. The audit found that an annual average of 2.4 million children enrolled in Medi-Cal (of the over 5.5 million children covered) do not receive all required preventive services. While DHCS adopted Bright Futures recommended schedule of care in 2014, the auditor found that DHCS’ contracts with plans continue to contain confusing language and DHCS does not ensure that plans clearly communicate the required Bright Futures services to their providers and beneficiaries. Moreover, DHCS requires plans to report on performance measures for only a portion of the services in Bright Futures. Utilization rates were higher in that portion of Bright Futures services that require reporting. Finally, the audit notes that while federal law requires DHCS to annually inform families of children who have not used EPSDT services of the benefits of preventive health care, and DHCS relies on the plans to do so. However, none of the plans contacted during the course of the audit performed this outreach.
2. Response to audit recommendations. To address the lack of information provided to plans, provider, and beneficiaries about the services children are expected to receive, the audit recommended that DHCS modify by May 2019 its contracts to make it clear to plans and providers that they are required to provide services according to Bright Futures. In response to the recommendation, DHCS agreed to update its All-Plan Letter and draft updated contract language pertaining to EPSDT to more explicitly state the requirement to use Bright Futures, but noted these recommendations could not be completed until November 1, 2019. A draft of the APL was released for stakeholder comment from late March to early April 2010 and is currently pending final review. DHCS also released a draft of the Evidence of Coverage that makes clearer the EPSDT benefits, which is expected to be finalized by July 1, 2019. Finally, current Medi-cal managed care plan boilerplate contracts already require MCPs to provide preventive health visits for all members under the age of 21 at times specified by the most recent AAP periodicity schedule. DHCS indicates there is an additional contract amendment that is already underway that makes clearer the AAP Bright Futures periodicity and anticipatory guidance requirements that Medi-Cal managed care plans must follow. The contract amendment is pending approval by CMS.

To improve access and utilization rates, the audit recommended that DHCS establish by March 2020 performance measures that cover Bright Futures services and require plans to track and report the utilization rates on those measures. In response to the audit recommendation, DHCS agreed to add measures from the CMS child core set to the External Accountability Set (EAS) and to increase the minimum performance level (MPL) for the EAS from the 25^th national percentile to the 50^th percentile. The CMS child core set includes the AAP Bright Futures developmental screening measures in the first three years of life. The EAS is a set of quality measures used to evaluate the quality of care delivered to beneficiaries. Federal regulations require DHCS to assess and improve the quality of care provided by Medi-Cal managed care plans. DHCS contracts with an external quality review organization EQRO to prepare an annual, independent technical report on beneficiary access to and quality of care, which in part, includes an analysis of the reported EAS measure. The CMS core set additions are expected to be included for the 2019 calendar year. DHCS also agreed to increase MCP sanctions, as appropriate, so that it may take quicker punitive action when MCP are found out of compliance. Finally, the Governor’s value-based purchasing initiative in the 2019-20 budget will now include supplemental funding for the provision of development and trauma screenings for all children under age 21.

1. AB 340 workgroup. AB 340 (Arambula, Chapter 700, Statutes of 2017) required DHCS, in consultation with the California Department of Social Services and other partners, to convene an advisory working group to update, amend, or develop, if appropriate, tools and protocols for screening children for trauma within EPSDT benefit. One of the workgroup’s tasks was to assess existing screening tools used in the Medi-Cal program, including the AAP Bright Futures periodicity schedule and guidance. As of January 2019, the initial workgroup has concluded and submitted its recommendations to DHCS and the Legislature. For purposes of trauma screening, the workgroup recommended another tool, the Pediatric ACEs and Related Life-Events Screener, accompany the Bright Futures and other existing state required screenings related to behavioral health and trauma.

Related/Prior Legislation

AB 11 (McCarty, 2018) was similar to this bill in that it would have required, consistent with federal law, screening services provided under EPSDT to include developmental screening services for individuals zero to three years of age. AB 11 would also have required the EQRO to annually review, survey, and report on Medi-Cal managed care plan reporting and compliance with the use of the validated developmental screening tools and periodicity schedule recommended for children zero to three years of age. AB 11 was vetoed by Governor Brown, who stated the Medi-Cal already requires providers to screen children for developmental delays according to the schedule recommended by the AAP, and codifying this requirement and producing another costly report is not necessary.

SB 1287 (Hernandez, Chapter 855, Statutes of 2018) defined in state law, for individuals under age 21 years of age enrolled in Medi-Cal, a service as medically necessary or a medical necessity by reference to the federal Medicaid standard, which requires coverage when the service would correct or ameliorate defects and physical and mental illnesses.

AB 340 (Arambula, Chapter 700, Statutes of 2017) required DHCS, in consultation with specified entities, to convene an advisory working group to update, amend, or develop, if appropriate, tools and protocols for the screening of children for trauma, within the EPSDT benefit, consistent with existing law.

SB 1466 (Mitchell of 2016) would have required screening services provided under the EPSDT Program to include screening for trauma, as defined, at all screenings. SB 1446 was vetoed by the Governor Brown, who stated this bill establishes a new trauma screening entitlement for every child on Medi-Cal, that Medi-Cal has grown from 8 million to 14 million beneficiaries since implementation of the federal Patient Protection and Affordable Care Act and provides coverage for over five million children, and given this dramatic expansion, he was reluctant to create another entitlement as required by the bill.

FISCAL EFFECT: Appropriation: No Fiscal Com.: Yes Local: No

According to the Senate Appropriations Committee, staff estimates low-hundreds of thousands for the EQRO entity to review and report metrics for developmental screenings costs. Contracting funds would be funded by 25 General Fund/75 federal funds. Staff notes unknown potentially high-tens of thousands, for DHCS administrative workload to review the EQRO’s technical report to monitor Medi-Cal managed care plans’ compliance. To the extent the department utilizes the EQRO’s technical report as part of existing compliance monitoring, staff notes costs could be negligible but are unknown at this time.

SUPPORT: (Verified 8/29/19)

Children Now (co-source)

First 5 LA (co-source)

American Academy of Pediatrics, California

CaliforniaHealth+ Advocates

County Health Executives Association of California

First 5 California

First 5 Sonoma County Commission

OPPOSITION: (Verified 8/29/19)

Department of Finance

ARGUMENTS IN SUPPORT: This bill is co-sponsored by First 5 LA and Children Now. First 5 LA, writing in support, state that pediatricians still often rely on surveillance alone, rather than a validated screening tool, to identify children at risk for developmental delays. Overall, just 37% of California pediatricians indicate that they use a validated or evidence-based screening tool to identify the majority of developmental concerns. This lack of consistency in practice has kept California as one of the lowest-performing states for developmental screening. Children Now writes that this bill helps to close crucial oversight and data gaps, and inform efforts to address the shortcomings in the state’s developmental screening practice going forward.

ARGUMENTS IN OPPOSITION: The Department of Finance is opposed to this bill, arguing the requirements of this bill are duplicative of recent actions taken by DHCS and the 2019-20 Budget.

ASSEMBLY FLOOR: 78-0, 5/23/19

AYES: Aguiar-Curry, Arambula, Bauer-Kahan, Berman, Bigelow, Bloom, Boerner Horvath, Bonta, Brough, Burke, Calderon, Carrillo, Cervantes, Chau, Chen, Chiu, Choi, Chu, Cooper, Cunningham, Dahle, Daly, Diep, Eggman, Flora, Fong, Frazier, Friedman, Gabriel, Gallagher, Cristina Garcia, Gipson, Gloria, Gonzalez, Gray, Grayson, Holden, Irwin, Jones-Sawyer, Kalra, Kamlager-Dove, Kiley, Lackey, Levine, Limón, Low, Maienschein, Mathis, Mayes, McCarty, Medina, Melendez, Mullin, Muratsuchi, Nazarian, Obernolte, O'Donnell, Patterson, Petrie-Norris, Quirk, Quirk-Silva, Ramos, Reyes, Luz Rivas, Robert Rivas, Rodriguez, Blanca Rubio, Salas, Santiago, Smith, Mark Stone, Ting, Voepel, Waldron, Weber, Wicks, Wood, Rendon

NO VOTE RECORDED: Cooley, Eduardo Garcia

Prepared by: Kimberly Chen / HEALTH / (916) 651-4111

9/3/19 11:05:20

**** END ****

SENATE COMMITTEE ON

Senator Anthony Portantino, Chair

2019 - 2020 Regular Session

AB 1004 (McCarty) - Developmental screening services

Bill Summary:

Assembly Bill 1004 would require, as part of Early and Periodic Screening and Diagnostic, and Treatment (EPSDT) benefit, developmental screenings for children ages zero to three years, inclusive. Would require the external review organization (EQRO), on or after July 1, 2020 ,and until July 1, 2023, to annually review, survey, and report on managed care plan compliance of specified screening tools.

*********** ANALYSIS ADDENDUM – SUSPENSE FILE ***********

The following information is revised to reflect amendments

adopted by the committee on August 30, 2019

Fiscal Impact:

Staff estimates low-hundreds of thousands for the EQRO entity to review and report metrics for developmental screenings costs. Contracting funds would be funded by 25 General Fund/75 federal funds. Staff notes unknown potentially high-tens of thousands, for DHCS administrative workload to review the EQRO’s technical report to monitor Medi-Cal managed care plans’ compliance. To the extent the department utilizes the EQRO’s technical report as part of existing compliance monitoring, staff notes costs could be negligible but are unknown at this time.

Author Amendments:

The author’s amendments would include the following:

• Require the EQRO to review and report on quality metrics for developmental screenings included in the Centers for Medicare and Medicaid Services (CMS) Core Set of Children’s Health Care Quality Measures for Medicaid and the Children’s Health Insurance Program, rather than on compliance with the tools and periodicity schedule recommended by the AAP/Bright Futures;
• Requires DHCS to use the EQRO’s technical report to monitor Medi-Cal managed care plan’s compliance with providing enrollees access to developmental screenings; and,
• Make other changes.

-- END --

SENATE COMMITTEE ON

Senator Anthony Portantino, Chair

2019 - 2020 Regular Session

AB 1004 (McCarty) - Developmental screening services

Bill Summary:

Assembly Bill 1004 would require, as part of Early and Periodic Screening and Diagnostic, and Treatment (EPSDT) benefit, developmental screenings for children ages zero to three years, inclusive. Would require the external review organization (EQRO), on or after July 1, 2020 and until July 1, 2023, to annually review, survey, and report on managed care plan compliance of specified screening tools.

Fiscal Impact:

According to the Department of Health Care Services (DHCS), $100,000 ($25,000 General Fund) annually for three years, for a total of $300,000, for the EQRO to conduct the survey on MCP reporting and compliance with the use of the validated developmental screening tools and periodicity schedule recommended by the AAP/Bright Futures for children zero to three years of age, inclusive. These contracting funds would be funded by 25 percent General Fund and 75 percent federal funds.

Background:

The DHCS administers the state’s Medi-Cal program, which provides health care services to qualified individuals who are low-income, including children aged 18 and under. Federal Medicaid law requires early and periodic screening, diagnostic, and treatment (EPSDT) services to include screening, vision, dental, hearing and other Medicaid health care, diagnostic services, treatment, and other measures to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services. Existing screening tools used in the Medi-Cal program, include the Staying Healthy Assessment developed by DHCS, the U.S. Preventive Services Task Force grade “A” or “B” recommendations, and the American Academy of Pediatrics (AAP) Bright Futures periodicity schedule.

EPSDT is a federally mandated benefit available to all Medi-Cal eligible individuals under the age of 21. Under EPSDT, Medi-Cal is required to provide comprehensive services and cover all medically necessary services needed to correct and ameliorate health conditions, including any medical, dental, vision, hearing, or mental health needs, so health problems are averted or diagnosed and treated as early as possible. The screening services must include a number of check-ups, including a physical exam; immunizations and laboratory tests; vision and dental services, and other services.

The Budget Act of 2019 includes $53.9 million ($23.1 million Proposition 56, $30.6 million federal funds) for new incentive payments for developmental screening services.

Proposed Law:

Assembly Bill 1004 would require, consistent with federal law, as part of Early and Periodic Screening and Diagnostic, and Treatment (EPSDT) benefit, developmental screenings for individuals ages zero to three years, inclusive.

The bill would require the DHCS to ensure that Medi-Cal managed care plans demonstrate ability and readiness to perform developmental screenings, and would require DHCS, as may be appropriate and in its discretion, to adjust the capitation rate of a Medi-Cal managed care plan to promote improved outcomes through value-based purchasing payment protocols to create improved incentives for outcomes.

The bill would provide that the bill does not limit or restrict required blood lead screenings required under existing law.

The bill would require the external review organization (EQRO), on or after July 1, 2020 and until July 1, 2023, to annually review, survey, and report on managed care plan compliance of specified screening tools.

Related Legislation:

• AB 537 (Wood) requires the DHCS to establish a quality assessment and performance improvement program for all Medi-Cal managed care plans, as specified. Requires DHCS to develop a plan for a value-based financial incentive program to reward a high-performing Medi-Cal managed plan that meets performance targets, as specified. AB 537 was held on the Assembly Appropriations Committee suspense file.
• AB 11 (McCarty, 2018) would have required, consistent with federal law, screening services provided under EPSDT to include developmental screening services for individuals zero to three years of age. AB 11 would also have required the EQRO to annually report on Medi-Cal managed care plan reporting and compliance with the use of the validated developmental screening tools and periodicity schedule. Governor Brown vetoed AB 11, stating Medi-Cal already requires providers to screen children for developmental delays according to the schedule recommended by the AAP, and codifying this requirement and producing another costly report is not necessary.

Staff Comments:

In March 2019, the State Auditor released a report on DHCS’s oversight of the delivery of preventive services to children in Medi-Cal, which found while DHCS requires plans to report on performance measures for only a portion of the services in Bright Futures, utilization rates were higher in that portion of Bright Futures services that require reporting.

In addition, staff notes the bill’s sponsor, First 5 California, identified successful models, such as Alameda County’s Help Me Grow or First 5 Santa Clara’s Universal Developmental Screening Initiative, which integrated a developmental screening tool in its programs to improve screening rates.

-- END --

SENATE COMMITTEE ON HEALTH

Senator Dr. Richard Pan, Chair

BILL NO: AB 1004

SUBJECT: Developmental screening services

SUMMARY:

Requires early and periodic screening, diagnostic, and treatment (EPSDT) screening services to include developmental screening services for Medi-Cal beneficiaries ages zero to three, inclusive. Requires Medi-Cal managed care plans to ensure contracted providers administering developmental screenings comply with the Bright Futures Guidelines and Recommendations for Preventive Pediatric Health Care established by the American Academy of Pediatrics (AAP). Requires the external quality review organization, beginning on July 1, 2020, to annually review Medi-Cal managed care plans for compliance with the use of the screenings tools and periodicity schedule recommended by APP.

Existing federal law: Requires EPSDT services to include screening, vision, dental, hearing and other Medicaid health care, diagnostic services, treatment, and other measures to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services. [42 USC §1396d]

Existing state law:

1. Establishes the Medi-Cal program, which is administered by the Department of Health Care Services (DHCS) and under which qualified low-income individuals receive health care services. [WIC §14000, et seq.]
2. Establishes a schedule of benefits in the Medi-Cal program, which includes the EPSDT program for any individual under 21 years of age, consistent with the specified requirements federal Medicaid law. [WIC §14132]
3. Requires the “medically necessity” standard, for purposes of services available to individuals under 21 years of age through the EPSDT program, to mirror the standards established in existing federal regulations. [WIC §14059.5]
4. Requires DHCS to convene an advisory group to update the protocols and tools for screening children for trauma within the EPSDT program. Requires the working group to consider existing screening tools, including but not limited to, the Staying Healthy Assessment developed by the department, the United States Preventive Services Task Force grade “A” or “B” recommendations, and the AAP Recommendations for Preventive Pediatric Health Care periodicity schedule and guidance. [WIC §14132.19]
5. Requires DHCS to convene a steering committee to provide advice and recommendations on the development of the Medi-Cal mental health managed care system and the delivery of services, including services provided to children through EPSDT. [WIC §14682.1]
6. Requires DHCS to require county MHPs to include a process for screening, referring, and coordinating services for eligible Medi-Cal beneficiaries, including coordination with education programs and any other necessary services for children, consistent with existing law. [WIC §14683]

This bill:

1. Requires EPSDT screening services to include developmental screening services for Medi-Cal beneficiaries ages zero to three, inclusive.
2. Requires Medi-Cal managed care plans to ensure and monitor compliance with the following:
   1. Developmental screening services provided by providers who contract with Medi-Cal managed care plans comply with the periodicity schedule and the standardized and validated developmental screening tools that are established by the APP Bright Futures Guidelines, and by any future updates to this material; and,
   2. Developmental screening tools are administered by providers who contract with Medi-Cal managed care plans in their entirety, and in adherence to, the specific tools’ recommended guidelines.
3. Prohibits this bill from limiting or restricting the scope of the EPSDT benefits for eligible Medi-Cal beneficiaries, pursuant to existing law.
4. Requires the external quality review organization (EQRO), beginning on or after July 1, 2020, to annually review, survey, and report on managed care plan compliance with the use of the validated developmental screening tools and periodicity schedule recommended by the APP for children zero to three years of age, inclusive. Sunsets this provision on July 1, 2023.
5. Authorizes DHCS to adjust the capitation rate of a Medi-Cal managed care plan to promote improved outcomes through value-based purchasing.

FISCAL EFFECT:

According to the Assembly Appropriations Committee:

1. Unknown costs to augment the EQRO contract to include additional potentially in the hundreds of thousands of dollars (General Fund [GF]/federal) annually, to review and report on the use of screening tools.
2. Cost pressure likely to exceed $10 million to provide value-based purchasing incentives to improve care in Medi-Cal managed care plans and for increased utilization of developmental screening and related services resulting from positive screens (GF or Proposition 56/federal). Improving developmental screening to identify potential issues sooner would also have some long-term cost savings associated with better developmental outcomes. The 2019-20 Governor's Budget includes a total of $45 million ($22.5 million Proposition 56/federal) to incentivize developmental screening.

PRIOR VOTES:

COMMENTS:

1. Author’s statement. According to the author, research has shown that earlier screenings make a positive impact on our youngest learners. Early identification and intervention can improve a child’s long-term outcome, and minimize the need for costly health care, special education, juvenile justice, and child welfare services down the road. This bill will also ensure that developmental screenings, which are shown to be very effective, are routinely occurring for infants and toddlers during Medi-Cal health care visits
2. EPSDT. EPSDT is a federally mandated benefit available to all Medi-Cal eligible individuals under the age of 21. Under EPSDT, Medi-Cal is required to provide comprehensive services and cover all medically necessary services needed to correct and ameliorate health conditions, including any medical, dental, vision, hearing, or mental health needs. The screening services must include a number of check-ups, including:
   1. Comprehensive health and developmental history;
   2. Physical exam;
   3. Appropriate immunizations;
   4. Laboratory tests;
   5. Health education;
   6. Vision services;
   7. Dental services;
   8. Hearing services, and,
   9. Other necessary health care services found to be medically necessary to treat, correct or reduce illnesses and conditions discovered regardless of whether the service is covered in the Medicaid State Plan.

According to Georgetown University Health Policy Institute, the last category includes terms with important nuances. First, the service must be considered medically necessary. A determination of whether a service is medically necessary must be made on a case-by-case basis, taking into account a particular child’s needs. Practically, this means that states may not impose hard limits on pediatric services because the service could be medically necessary for some children. States may impose tentative limits on services pending an individualized determination, a decision shared by the state and the child’s treating provider. Second, the service must be provided regardless of whether it is covered under the State Plan, the agreement between the state and the federal government describing how a state will administer its Medicaid program. This means that Medi-Cal may provide services under the EPSDT program that may not be available to other Medi-Cal enrollees. When a screening indicates a need for further evaluation, EPSDT covers diagnostic services and ultimately any services necessary to treat the identified health problems.

1. Bright Futures. According to DHCS, the Affordable Care Act (ACA) specified that coverage of preventive care and screenings must be conducted with evidence-informed, comprehensive guidelines supported by the Health Resources and Services Administration (HRSA), which is an agency of the U.S. Department of Health and Human Services. The HRSA participated in the development of, and provides ongoing support to, the national health promotion and prevention initiative known as Bright Futures, which is led by the AAP. The AAP develops theory-based and evidence-based driven guidance and recommendations for preventive care screenings and well-child visits for children and regularly publishes updated tools and resources for use by clinicians and state agencies. These tools include the “Bright Futures Guidelines” and the “Recommendations for Preventive Pediatric Health Care,” which is also known as the “periodicity schedule”. The ACA mandates the use of the Bright Futures periodicity schedule and guidelines when delivering the EPSDT benefit.

The Child Health and Disability Prevention Program (CHDP) is responsible for the screening component of the EPSDT benefit of the Medi-Cal program. CHDP issues guidelines to set CHDP provider standards for pediatric health assessments for children served by the CHDP Program. DHCS indicates these guidelines are consistent with the AAP Bright Futures Guidelines and the MCP contracts require MCP to provide all age-specific assessments consistent with Bright Futures.

1. State Auditor report findings. In March 2019, the State Auditor released an audit report on DHCS’s oversight of the delivery of preventive services to children in Medi-Cal. The audit found that an annual average of 2.4 million children enrolled in Medi-Cal (of the over 5.5 million children covered) do not receive all required preventive services. While DHCS adopted Bright Futures recommended schedule of care in 2014, the auditor found that DHCS’ contracts with plans continue to contain confusing language and DHCS does not ensure that plans clearly communicate the required Bright Futures services to their providers and beneficiaries. Moreover, DHCS requires plans to report on performance measures for only a portion of the services in Bright Futures. Utilization rates were higher in that portion of Bright Futures services that require reporting. Finally, the audit notes that while federal law requires DHCS to annually inform families of children who have not used EPSDT services of the benefits of preventive health care, and DHCS relies on the plans to do so. However, none of the plans contacted during the course of the audit performed this outreach.
2. Response to audit recommendations. To address the lack of information provided to plans, provider, and beneficiaries about the services children are expected to receive, the audit recommended that DHCS modify by May 2019 its contracts to make it clear to plans and providers that they are required to provide services according to Bright Futures. In response to the recommendation, DHCS agreed to update its All-Plan Letter and draft updated contract language pertaining to EPSDT to more explicitly state the requirement to use Bright Futures, but noted these recommendations could not be completed until November 1, 2019. A draft of the APL was released for stakeholder comment from late March to early April 2010 and is currently pending final review. DHCS also released a draft of the Evidence of Coverage (EOC) that makes clearer the EPSDT benefits, which is expected to be finalized by July 1, 2019. Finally, current Medi-cal managed care plan boilerplate contracts already require MCPs to provide preventive health visits for all members under the age of 21 at times specified by the most recent AAP periodicity schedule. DHCS indicates there is an additional contract amendment that is already underway that makes clearer the AAP Bright Futures periodicity and anticipatory guidance requirements that Medi-Cal managed care plans must follow. The contract amendment is pending approval by the Centers for Medicare and Medicaid Services (CMS).

To improve access and utilization rates, the audit recommended that DHCS establish by March 2020 performance measures that cover Bright Futures services and require plans to track and report the utilization rates on those measures. In response to the audit recommendation, DHCS agreed to add measures from the CMS child core set to the External Accountability Set (EAS) and to increase the minimum performance level (MPL) for the EAS from the 25^th national percentile to the 50^th percentile. The EAS is a set of quality measures used to evaluate the quality of care delivered to beneficiaries. Federal regulations require DHCS to assess and improve the quality of care provided by Medi-Cal managed care plans. DHCS contracts with an external quality review organization EQRO to prepare an annual, independent technical report on beneficiary access to and quality of care, which in part, includes an analysis of the reported EAS measure. The CMS child core set includes development screening measures in the first three years of life. The CMS core set additions are expected to be included for the 2019 calendar year. DHCS also agreed to increase MCP sanctions, as appropriate, so that it may take quicker punitive action when MCP are found out of compliance. Finally, the Governor’s value-based purchasing initiative in the 2019-20 budget will now include supplemental funding for the provision of development and trauma screenings for all children under age 21.

1. AB 340 workgroup. AB 340 (Arambula, Chapter 700, Statutes of 2017) required DHCS, in consultation with the California Department of Social Services (CDSS) and other partners, to convene an advisory working group to update, amend, or develop, if appropriate, tools and protocols for screening children for trauma within EPSDT benefit. One of the workgroup’s tasks was to assess existing screening tools used in the Medi-Cal program, including the AAP Bright Futures periodicity schedule and guidance. As of January 2019, the initial workgroup has concluded and submitted its recommendations to DHCS and the Legislature. For purposes of trauma screening, the workgroup recommended another tool, the Pediatric ACEs and Related Life-Events Screener (PEARLS), accompany the Bright Futures and other existing state required screenings related to behavioral health and trauma.
2. Related legislation. AB 537 (Wood) requires DHCS to establish a quality assessment and performance improvement program for all Medi-Cal managed care plans which requires plans to meet a MPL that improves quality of care and reduces health disparities for beneficiaries. Requires DHCS to develop a plan for a value-based financial incentive program to reward a high-performing Medi-Cal managed plan that meets performance targets, established by DHCS and that demonstrate health care quality improvement and health disparities reduction. AB 537 was held on the Assembly Appropriations suspense file.
3. Prior legislation. AB 11 (McCarty of 2018) was similar to this bill in that it would have required, consistent with federal law, screening services provided under EPSDT to include developmental screening services for individuals zero to three years of age. AB 11 would also have required the EQRO to annually review, survey, and report on Medi-Cal managed care plan reporting and compliance with the use of the validated developmental screening tools and periodicity schedule recommended for children zero to three years of age. AB 11 was vetoed by Governor Brown, who stated the Medi-Cal already requires providers to screen children for developmental delays according to the schedule recommended by the AAP, and codifying this requirement and producing another costly report is not necessary.

SB 1287 (Hernandez, Chapter 855, Statutes of 2018) defines in state law, for individuals under age 21 years of age enrolled in Medi-Cal, a service as medically necessary or a medical necessity by reference to the federal Medicaid standard, which requires coverage when the service would correct or ameliorate defects and physical and mental illnesses.

AB 340 (Arambula, Chapter 700, Statutes of 2017) requires DHCS, in consultation with specified entities, to convene an advisory working group to update, amend, or develop, if appropriate, tools and protocols for the screening of children for trauma, within the EPSDT benefit, consistent with existing law.

SB 1466 (Mitchell of 2016) would have required screening services provided under the EPSDT Program to include screening for trauma, as defined, at all screenings. SB 1446 was vetoed by the Governor Brown, who stated this bill establishes a new trauma screening entitlement for every child on Medi-Cal, that Medi-Cal has grown from 8 million to 14 million beneficiaries since implementation of the federal Patient Protection and Affordable Care Act and provides coverage for over five million children, and given this dramatic expansion, he was reluctant to create another entitlement as required by the bill.

1. Support. This bill is co-sponsored by First 5 LA and Children Now. First 5 LA, writing in support, state that pediatricians still often rely on surveillance alone, rather than a validated screening tool, to identify children at risk for developmental delays. Overall, just 37% of California pediatricians indicate that they use a validated or evidence-based screening tool to identify the majority of developmental concerns. This lack of consistency in practice has kept California as one of the lowest-performing states for developmental screening. Children Now writes that this bill helps to close crucial oversight and data gaps, and inform efforts to address the shortcomings in the state’s developmental screening practice going forward.

American Academy of Pediatrics, California (AAP-CA) also supports this bill. AAP-CA writes that Bright Futures recommend all infants and toddlers under the age of three receive routine developmental screenings as part of a well-child visit. Early identification of developmental delays through screening is the first step to connecting children with support for healthy development. AACP-CA believes this bill will would help to ensure that every California child, especially those who are low-income, has the opportunity to reach their full potential by having timely developmental screenings in Medi-Cal.

1. Policy comment. As a result of the March 2019 State Auditor report, DHCS has taken additional steps to make clear the Bright Futures Guidelines and periodicity schedule requirements for Medi-Cal managed care plans. DHCS has also added the full CMS child core set to its EAS measures, which will be part of the EQRO’s annual report. Developmental and trauma screenings will also be eligible for incentive payments under the new value-based initiative in Medi-Cal. These actions address the issues this bill intends to address. It is unclear whether this bill is still necessary at this time.
2. Technical amendments. The author proposes technical amendments to make clear that this bill does not restrict blood lead screenings required under existing law and to add co-authors.

SUPPORT AND OPPOSITION:

Support: First 5 LA (co-sponsor)

Children Now (co-sponsor)

American Academy of Pediatrics, California

CaliforniaHealth+ Advocates

County Health Executives Association of California

First 5 California

First 5 Sonoma County Commission

Oppose: None received

-- END --

ASSEMBLY THIRD READING

ATR Bill Id:AB 1004

Author:(McCarty)

As Amended Ver:April 23, 2019

Majority vote

SUMMARY:

Requires, consistent with federal law, screening services provided as an Early and Periodic Screening, Diagnosis, and Treatment Medi-Cal benefit to include developmental screening services for individuals zero to three years of age. Requires Medi-Cal Managed Care (MCMC) plans to ensure and monitor compliance with developmental screening services provided by providers who contract with MCMC plans to ensure compliance with the periodicity schedule and the standardized and validated developmental screening tools established by the Bright Futures Guidelines and Recommendations for Preventive Pediatric Health Care (Bright Futures), as established by the American Academy of Pediatrics (AAP), and developmental screening tools are administered by contracted providers in their entirety and in adherence to, the specific tools' recommended guidelines. Requires, until July 1, 2023, as part of the federally required external quality review organization (EQRO) review of MCMC plans, the EQRO entity to annually review, survey, and report on MCMC plan reporting and compliance with the use of the validated developmental screening tools and periodicity schedule recommended by the AAP for children zero to three years of age, inclusive. Requires the Department of Health Care Services (DHCS) to ensure that MCMC plans demonstrate ongoing ability and readiness to perform the monitoring of developmental screening in this bill. Requires DHCS, as may be appropriate and in its discretion, to adjust the capitation rate of a MCMC plan to promote improved outcomes through value-based purchasing payment protocols to create improved incentives for outcomes.

Major Provisions

COMMENTS:

Focused study on development screening. In 2016, DHCS contracted with its EQRO to conduct a focused study to help DHCS determine if Common Procedural Terminology (CPT) Code 96110 (CPT Code 96110 is a code for developmental screening) could be used to evaluate plans' rates for the "Developmental Screening in the First Three Years of Life" measure in California as DHCS considered the potential inclusion of this measure in its External Accountability Set. Of the 23 plans that received the questionnaire, the EQRO received 20 distinct responses, with two plans not responding and two plans submitting a combined response due to their contractual setup. In reporting the results, DHCS indicated statewide coding rate for CPT 96110 at 1, 2, and 3 years of age was 54.8%, 41.1%, and 30.8 respectively, with a total over three years of 36.4%. DHCS indicated the questionnaires identified similar barriers, including lack of education on the importance of children receiving development screening (provider and beneficiary), resource constrains, lack of referral services and/or pathways, inconsistent use of standardized tools, inconsistent use of CPT 96110, and data reporting issues so that it cannot be accurately assessed whether or not a child has received developmental screening.

ADMINISTRATION PROPOSAL. Governor Newsom's 2019-20 budget proposes to use Proposition 56 funding to support the provision of both developmental and trauma screenings for all children ages 0-21, as well as support trauma screenings for all adults with full-scope coverage in Medi-Cal. DHCS indicates these screenings will be billed and reimbursed in both MCMC and fee-for-service delivery systems. These payments will be in addition to the amounts paid generally for the office visit in fee-for-service scenarios or capitation paid by managed care plans. The budget estimates that these screenings will spend $52.5 million of Proposition 56 funding.

According to the Author:

Research has shown that earlier screenings make a positive impact on our youngest learners. Early identification and intervention can improve a child's long-term outcome, and minimize the need for costly health care, special education, juvenile justice, and child welfare services down the road. This bill will also ensure that developmental screenings, which are shown to be very effective, are routinely occurring for infants and toddlers during Medi-Cal health care visits.

Arguments in Support:

This bill is jointly sponsored by Children Now and First 5 LA, which argue that by establishing clear guidelines and oversight for developmental screenings for children ages 0-3 years old, delays will be identified earlier and California's children will be more likely to achieve their greatest potential. Currently, California ranks just 43rd in the nation for parents completing timely developmental screenings. First 5 LA states the AAP established Bright Futures guidelines for developmental screenings nearly 20 years ago, but pediatricians still often rely on surveillance alone, rather than a validated screening tool, to identify children at risk for developmental delays. Overall, just 37% of California pediatricians indicate that they use a validated or evidence-based screening tool to identify the majority of developmental concerns. This lack of consistency in practice has kept California as one of the lowest-performing states for developmental screening. First 5 LA states that 70% of children with delays go undetected until kindergarten, which creates additional demands for California's special education system and puts California children at a serious disadvantage.

Arguments in Opposition:

There is no known opposition.

FISCAL COMMENTS:

According to the Assembly Appropriations Committee:

1. Unknown costs to augment the EQRO contract to include additional potentially in the hundreds of thousands of dollars (General Fund (GF)/federal) annually, to review and report on the use of screening tools.
2. Cost pressure likely to exceed $10 million to provide value-based purchasing incentives to improve care in Medi-Cal managed care plans and for increased utilization of developmental screening and related services resulting from positive screens (GF or Proposition 56/federal). Improving developmental screening to identify potential issues sooner would also have some long-term cost savings associated with better developmental outcomes. The 2019-20 Governor's Budget includes a total of $45 million ($22.5 million Proposition 56/federal) to incentivize developmental screening.

VOTES:

ASM HEALTH: 15-0-0

YES: Wood, Mayes, Aguiar-Curry, Bigelow, Bonta, Burke, Wicks, Flora, Limón, McCarty, Nazarian, Ramos, Rodriguez, Santiago, Waldron

ASM APPROPRIATIONS: 18-0-0

YES: Gonzalez, Bigelow, Bloom, Bonta, Brough, Calderon, Carrillo, Chau, Diep, Eggman, Fong, Gabriel, Eduardo Garcia, Maienschein, Obernolte, Petrie-Norris, Quirk, Robert Rivas

UPDATED:

VERSION: April 23, 2019

CONSULTANT: Scott Bain / HEALTH / (916) 319-2097 FN: 0000704

Date of Hearing: April 9, 2019

ASSEMBLY COMMITTEE ON HEALTH

Jim Wood, Chair

ABPCA Bill Id:AB 1004

Author:(McCarty) – As Introduced Ver:February 21, 2019

SUBJECT: Developmental screening services.

SUMMARY: Requires developmental screening services provided under the Medi-Cal program to comply with the periodicity schedule and the standardized and validated developmental screening tools that are established by the Bright Futures Guidelines and Recommendations for Preventive Pediatric Health Care (Bright Futures), as established by the American Academy of Pediatrics (AAP). Requires developmental screening tools to be administered in their entirety, and in adherence to, the specific tools’ recommended guidelines. Requires the Department of Health Care Services (DHCS), as may be appropriate and in its discretion, to adjust a Medi-Cal managed care (MCMC) plan’s capitation rate to promote improved outcomes through value-based purchasing payment protocols to create improved incentives for outcomes. Specifically, this bill:

1. Requires, consistent with federal law, screening services provided as an Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) benefit to include developmental screening services for individuals zero to three years of age, inclusive.
   
2. Requires developmental screening services to comply with the periodicity schedule and the standardized and validated developmental screening tools that are established by Bright Futures, as established by the AAP, and by any future updates to this material.
   
3. Requires developmental screening tools to be administered in their entirety, and in adherence to the specific tools’ recommended guidelines.
   
4. Requires DHCS to ensure the MCMC plan’s ongoing ability and readiness to perform the development screening obligations set forth in this bill in 1) through 3) above.
5. Requires DHCS, as may be appropriate and in its discretion, to adjust a MCMC plan’s capitation rate to promote improved outcomes through value-based purchasing payment protocols to create improved incentives for outcomes.
6. Requires DHCS, as part of an evaluation DHCS must perform before a MCMC plan commences operations in a geographic area, to evaluate the MCMC plan’s mechanisms for ensuring timely and consistent developmental screenings of children in accordance with its contract with DHCS and the requirements of this bill.
   
7. Requires, as part of the federally required external quality review organization (EQRO) review of MCMC plans in the annual detailed technical report required under existing federal regulation, the EQRO entity to annually review, survey, and report on MCMC plan reporting and compliance with the use of the validated developmental screening tools and periodicity schedule recommended by the AAP for children zero to three years of age, inclusive. Sunsets and repeals this provision July 1, 2023.
8. Makes legislative findings and declarations regarding the activities of First 5, low rates of screening, the Bright Futures Guidelines by the AAP, and the purpose of developmental screening schedule up to 30 months.
   

EXISTING LAW:

1. Establishes the Medi-Cal program, which is administered by DHCS and under which qualified low-income individuals receive health care services.
   
2. Makes children age 18 and under with incomes up to 266% of the federal poverty level eligible for Medi-Cal.
3. Establishes a schedule of benefits in the Medi-Cal program, which includes EPSDT program for any individual under 21 years of age, consistent with the requirements of a specified EPSDT provision of federal Medicaid law.
4. Requires DHCS, before a MCMC plan commences operations based upon an action of the director that expands the geographic area of MCMC, to perform an evaluation to determine the readiness of any affected MCMC plan to commence operations. Requires the evaluation to include specified components.
5. Requires DHCS, in consultation with the Department of Social Services, county mental health experts, managed care plan experts, behavioral health experts, child welfare experts, and stakeholders, to convene an advisory working group to update, amend, or develop, if appropriate, tools and protocols for the screening of children for trauma, within the EPSDT benefit, consistent with existing law.
   
6. Requires the advisory working group to consider both of the following:
   
7. Existing screening tools used in the Medi-Cal program, including, but not limited to, the Staying Healthy Assessment developed by DHCS, the U.S. Preventive Services Task Force grade “A” or “B” recommendations, and the AAP Bright Futures periodicity schedule and anticipatory guidance; and,
8. The efficacy and appropriateness of the types of providers authorized to administer screenings.
9. Requires DHCS to convene the advisory working group by May 1, 2018, requires the advisory working group to report its findings and recommendations, as well as any appropriations necessary to implement those recommendations, to DHCS and to the Legislature’s budget subcommittees on health and human services no later than May 1, 2019. Disbands the advisory working group on December 31, 2019.
10. Prohibits findings or recommendations of the advisory working group that cannot be implemented without a subsequent appropriation by the Legislature, as determined by DHCS from being implemented until the appropriation is made.

FISCAL EFFECT: This bill has not yet been analyzed by a fiscal committee.

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, research has shown that earlier screenings make a positive impact on our youngest learners. Early identification and intervention can improve a child’s long-term outcome, and minimize the need for costly health care, special education, juvenile justice, and child welfare services down the road. This bill will also ensure that developmental screenings, which are shown to be very effective, are routinely occurring for infants and toddlers during Medi-Cal health care visits.
2. EPSDT. EPSDT is the children’s health benefit in Medicaid. Under federal Medicaid law, EPSDT services include screening, vision, dental, hearing, and other Medicaid health care, diagnostic services, treatment, and other measures to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services. The purpose of EPSDT is to discover and treat childhood health conditions before they become serious or disabling. States must inform all Medicaid-eligible families about the benefit, screen children at reasonable intervals, diagnose and treat any health problems found, and report certain data regarding EPSDT participation annually to the Centers for Medicare & Medicaid Services. The EPSDT benefit is more robust than the Medi-Cal benefit package provided to adults. For example, services that are optional benefits under federal law for adults in Medi-Cal (such as dental, eyeglasses, physical and occupational therapy and pharmacy) are required goods and services under EPSDT. The EPSDT benefit is designed to ensure that eligible members receive early detection and preventive care in addition to medically necessary treatment services, so that health problems are averted or diagnosed and treated as early as possible.
3. Bright Futures. The Child Health and Disability Prevention Program (CHDP) is responsible for the screening component of the EPSDT benefit of the Medi-Cal program, including the health assessments, immunizations, and laboratory screening procedures for Medi-Cal children. CHDP issues guidelines to set CHDP provider standards for pediatric health assessments for children served by the CHDP Program. DHCS indicates these guidelines are consistent with the AAP Bright Futures Guidelines and provide guidance to ensure compliance with California state specific regulations, and that all CHDP providers are required to comply with the most recent AAP Bright Futures Guidelines and the AAP Bright Futures Recommendations for Preventive Pediatric Health Care. DHCS indicates that the CHDP Program is continuing to update the CHDP Guidelines to meet Bright Futures Guidelines, as well as state regulations that may supersede some of the Bright Futures periodicity requirements for screening and testing. As a result, there may be some differences between the CHDP Guidelines and Bright Futures Guidelines.
   
4. Focused study on development screening. In 2016, DHCS contracted with its EQRO to conduct a focused study to help DHCS determine if Common Procedural Terminology Code 96110 (CPT Code 96110 is a code for developmental screening) could be used to evaluate plans’ rates for the “Developmental Screening in the First Three Years of Life” measure in California as DHCS considered the potential inclusion of this measure in its External Accountability Set. The objective of the focus study was to determine to what extent CPT Code 96110 can be used to evaluate Medi-Cal managed plans’ rates for at “Developmental Screening in the First Three Years of Life” measure in California. DHCS had concerns that the rates for this measure would be artificially low due to provider lack of use of the CPT Code 96110 (for example, providers who are capitated or working in FQHCs have no incentive to use the code as it does not result in additional payment).
   
   The EQRO distributed the Developmental Screening in the First Three Years of Life measure questionnaire to 23 MCMC plans in February 2017. The EQRO then reviewed MCMC plans’ questionnaire responses and followed up with them, if necessary, in March and April 2017. Of the 23 plans that received the questionnaire, the EQRO received 20 distinct responses, with two plans not responding and two plans submitting a combined response due to their contractual setup. DHCS reported the Focus Study Results at a September 17, 2017 meeting of the MCMC Advisory Group. DHCS indicated statewide coding rate for CPT 96110 at 1, 2, and 3 years of age was 54.8%, 41.1%, and 30.8 respectively, with a total over three years of 36.4%. DHCS indicated the questionnaires identified similar barriers, including lack of education on the importance of children receiving development screening (provider and beneficiary), resource constrains, lack of referral services and/or pathways, inconsistent use of standardized tools, inconsistent use of CPT 96110, and data reporting issues so that it cannot be accurately assessed whether or not a child has received developmental screening.
   
5. BUREAU OF STATE AUDITS (BSA). In March 2019, BSA released an audit entitled “Department of Health Care Services - Millions of Children in Medi-Cal Are Not Receiving Preventive Health Services” regarding DHCS' oversight of the delivery of preventive services to children in Medi-Cal found the following:
   1. An annual average of 2.4 million children enrolled in Medi-Cal do not receive all required preventive services;
   2. Many of the State's children do not have adequate access to Medi-Cal providers who can deliver the required pediatric preventive services;
   3. Limited provider access is due, in part, to low Medi-Cal reimbursement rates;
   4. States with higher utilization rates offer financial incentive programs that California could implement, but it would likely require additional funding;
   5. DHCS delegates responsibilities to ensure access and use of children's preventive services to MCMC plans, but it does not provide effective guidance and oversight:
      1. It does not provide adequate information to plans, providers, and beneficiaries about the services it expects children to receive;
      2. It does not ensure that plans regularly identify and address underutilization of children's preventive services; and,
      3. It has not followed up on plans' efforts to mitigate cultural disparities in the usage of preventive services.

BSA made several recommendations for the Legislature and DHCS relevant to the provisions of this bill, including that the Legislature should direct DHCS to implement a pay-for-performance program targeted specifically at ensuring that plans are more consistently providing preventive services to children in Medi-Cal. In addition, BSA recommended DHCS establish performance measures for Bright Futures services for all age groups and require plans to track and report the utilization rates on those measures. BSA also recommended that DHCS, to ensure that health plans and providers are adequately delivering children’s preventive services, should conduct audit procedures through its annual medical audits that address the delivery of EPSDT services to all eligible children for all plans.

1. ADMINISTRATION PROPOSAL. Governor Newsom’s 2019-20 budget proposes to use Proposition 56 funding to support the provision of both developmental and trauma screenings for all children ages 0-21, as well as support trauma screenings for all adults with full-scope coverage in Medi-Cal. DHCS indicates these screenings will be billed and reimbursed in both MCMC and fee-for-service delivery systems. These payments will be in addition to the amounts paid generally for the office visit in fee-for-service scenarios or capitation paid by managed care plans. The budget estimates that these screenings will spend $52.5 million of Proposition 56 funding.
   
2. SUPPORT. This bill is jointly sponsored by Children Now and First 5 LA, which argue that by establishing clear guidelines and oversight for developmental screenings for children ages 0-3 years old, delays will be identified earlier and California’s children will be more likely to achieve their greatest potential. Currently, California ranks just 43rd in the nation for parents completing timely developmental screenings. First 5 LA states the AAP established Bright Futures guidelines for developmental screenings nearly 20 years ago, but pediatricians still often rely on surveillance alone, rather than a validated screening tool, to identify children at risk for developmental delays. Overall, just 37% of California pediatricians indicate that they use a validated or evidence-based screening tool to identify the majority of developmental concerns. This lack of consistency in practice has kept California as one of the lowest-performing states for developmental screening. First 5 LA states that 70% of children with delays go undetected until kindergarten, which creates additional demands for California’s special education system and puts California children at a serious disadvantage.

By requiring an EQRO review, this bill will help close crucial oversight and data gaps, and inform efforts to address the shortcomings in the state’s developmental screening practices going forward. This will better allow California’s children, especially those who are low income and the most at risk for delay, to receive the timely developmental screenings that are so critical to ensuring their optimal growth and development.

1. RELATED LEGISLATION. AB 537 (Wood) requires DHCS to establish a quality assessment and performance improvement program for all MCMC plans which requires plans to meet a minimum performance level (MPL) that improves quality of care and reduces health disparities for beneficiaries; Requires DHCS, commencing July 1, 2022, to establish quality improvement performance targets which exceed the MPL for all MCMC plans; requires DHCS to develop a plan for a value-based financial incentive program to reward a high-performing MCMC plan that meets performance targets that demonstrate health care quality improvement and health disparities reduction; requires DHCS to utilize the results of the quality assessment and performance improvement program to develop a publicly reported Quality Rating System for MCMC plans; and, requires DHCS to establish a public stakeholder process in the planning, development, and ongoing oversight of the quality assessment and performance improvement program and the value-based financial incentive program. AB 537 is pending in the Assembly Health Committee.
   
   AB 1004 (McCarty) requires developmental screening services provided under the Medi-Cal program to comply with the periodicity schedule and the standardized and validated developmental screening tools that are established by the AAP Bright Futures; Requires developmental screening tools to be administered in their entirety, and in adherence to, the specific tools’ recommended guidelines; Requires the DHCS, as may be appropriate and in its discretion, to adjust a MCMC plan’s capitation rate to promote improved outcomes through value-based purchasing payment protocols to create improved incentives for outcomes.
   
   AB 1642 (Wood) requires Medi-Cal capitation rates paid to MCMC plans to take into account beneficiary access to Medi-Cal covered services, including travel times to receive services and the ability of a MCMC plan to comply with the time and distance requirements and appointment availability standards without seeking authorization from DHCS to adopt alternative access standards; increases the civil penalty in existing law, from $25,000 to $100,000, if a MCMC plan fails to provide medically necessary services that the plan is required to provide; Authorizes a civil penalty if the MCMC fails to achieve the 50^th percentile of the Medicaid managed care plan MPL on quality measures established by DHCS. Requires DHCS, subject to the availability of funding, to conduct a preventive services outreach and education program for Medi-Cal beneficiaries; Requires a MCMC that has received approval from DHCS to utilize an alternative access standard to assist an enrollee who is required to travel farther than the time and distance standards for that geographic area in obtaining an appointment with an appropriate out-of-network provider within the geographic area the appointment time standards; and, requires the MCMC, if an out-of-network provider is unavailable within the appointment tine standards, to arrange for nonmedical transportation for an enrollee to obtain covered Medi-Cal services. AB 1642 is scheduled to be heard in the Assembly Health Committee on April 9, 2019.
2. PREVIOUS LEGISLATION. AB 11 (McCarty) was similar to this bill in that it would have required, consistent with federal law, screening services provided under EPSDT to include developmental screening services for individuals zero to three years of age. AB 11 would also have required the EQRO to annually review, survey, and report on MCMC plan reporting and compliance with the use of the validated developmental screening tools and periodicity schedule recommended for children zero to three years of age. AB 11 was vetoed by Governor Brown, who stated the Medi-Cal State Plan already requires providers to screen children for developmental delays according to the schedule recommended by the AAP, and codifying this requirement and producing another costly report is not necessary.

SB 1287 (Hernandez), Chapter 855, Statutes of 2018, defines in state law, for individuals under age 21 years of age enrolled in Medi-Cal, a service as medically necessary or a medical necessity by reference to the federal Medicaid standard, which requires coverage when the service would correct or ameliorate defects and physical and mental illnesses.

AB 340 (Arambula), Chapter 700, Statutes of 2017, requires DHCS, in consultation with specified entities, to convene an advisory working group to update, amend, or develop, if appropriate, tools and protocols for the screening of children for trauma, within the EPSDT benefit, consistent with existing law.

AB 470 (Arambula), Chapter 550, Statutes of 2017, requires the DHCS to consult with specified stakeholders to inform the updates to the performance outcomes system for specialty mental health services (SMHS) developed for the EPSDT Program and under the Special Terms and Conditions of the Medi-Cal SMHS Waiver.

SB 1466 (Mitchell) of 2016, would have required screening services provided under the EPSDT Program to include screening for trauma, as defined, at all screenings. SB 1446 was vetoed by the Governor. In his veto message, the Governor stated this bill establishes a new trauma screening entitlement for every child on Medi-Cal, that Medi-Cal has grown from 8 million to 14 million beneficiaries since implementation of the federal Patient Protection and Affordable Care Act and provides coverage for over five million children, and given this dramatic expansion, he was reluctant to create another entitlement as required by the bill.

1. Policy question: How to improve MCMC plan and health care provider performance? This bills takes several approaches to increase low developmental screening rates, including requiring DHCS to monitor evaluate MCMC plans’ mechanisms for ensuring development screening, requiring DHCS (as appropriate) to adjust a MCMC plan’s capitation’s rate to promote improved outcomes (in effect, pay-for-performance), and by requiring a time-limited external review of plan compliance the developmental screening tools and the periodicity schedule.
   
   This bill also requires developmental screening services to comply with the periodicity schedule and the standardized and validated developmental screening tools that are established by the Bright Futures, and further requires developmental screening tools to be administered in their entirety, and in adherence to, the specific tools’ recommended guidelines. This requirements is placed in the Welfare and Institutions Code in the Medi-Cal benefits provision of law, but is effectively a mandate on pediatric health care providers. However, screening guidelines are intended for use by health care providers based on medical evidence, as opposed to being codified in law. The author may wish, as an alternative to the health care provider obligation in this bill, requiring plans to monitor compliance with and ensure their contracting pediatric providers are adhering to the developmental screening provisions of this measure.
   
2. DRAFTING ISSUE. Section 2 of this bill requires DHCS, as appropriate to adjust plan’s capitation payments to promote improved outcomes. Staff recommends this provision be moved to the MCMC rate-setting provisions in existing law.
   

REGISTERED SUPPORT / OPPOSITION:

Support

Children Now (cosponsor)

First 5 LA (cosponsor)

American Academy of Pediatrics

Children and Families Commission of Los Angeles County
County Health Executives Association of California

First 5 Sonoma County

Opposition

None on file.

Analysis Prepared by: Scott Bain / HEALTH / (916) 319-2097

Date of Hearing: May 8, 2019

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Lorena Gonzalez, Chair

ABPCA Bill Id:AB 1004

Author:(McCarty) – As Amended Ver:April 23, 2019

Urgency: No State Mandated Local Program: No Reimbursable: No

SUMMARY:

This bill implements measures designed to ensure the success of developmental screening for children in Medi-Cal. Specifically, this bill:

1. Requires screening services available under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit for children in Medi-Cal to include developmental screening services for individuals zero to three years of age.
2. Requires the Department of Health Care Services (DHCS) to contract with an existing external quality review organization (EQRO) to annually review, survey and report on managed care plan reporting and compliance with the use of the validated developmental screening tools and recommended screening schedule.
3. Requires Medi-Cal managed care plans to require their contracted providers to comply with the established periodicity schedule for developmental screenings to ensure adherence to standardized tools and to recommended guidelines for developmental screening.
4. Allows DHCS to adjust capitation rates to managed care plans to promote improved outcomes by using value-based purchasing.

FISCAL EFFECT:

1. Unknown costs to augment the EQRO contract to include additional potentially in the hundreds of thousands of dollars (GF/federal) annually, to review and report on the use of screening tools.
2. Cost pressure likely to exceed $10 million to provide value-based purchasing incentives to improve care in Medi-Cal managed care plans and for increased utilization of developmental screening and related services resulting from positive screens (GF or Proposition 56/federal). Improving developmental screening to identify potential issues sooner would also have some long-term cost savings associated with better developmental outcomes. The 2019-20 Governor’s Budget includes a total of $45 million ($22.5 million Proposition 56/federal) to incentivize developmental screening.

COMMENTS:

1. Purpose. According to the author, early identification and intervention can improve long-term outcomes for children and minimize the need for costly health care, special education, juvenile justice and child welfare services down the road. This bill will also ensure that developmental screenings, which are shown to be very effective, are routinely occurring for infants and toddlers during Medi-Cal health care visits. This bill is sponsored by Children Now and First 5 LA.
2. Background. Medi-Cal coverage for children includes enumerated preventive health and developmental screenings. This bill requires screenings to include those established by the Bright Futures/ American Academy of Pediatrics (AAP) Periodicity Schedule. Bright Futures is a national health promotion and prevention initiative, led by the AAP and supported, in part, by federal governmental health agencies. The periodicity schedule provides evidence-based guidance for preventive care screenings and well-child visits. It includes recommended procedures, measurements and exams for each visit according to a child's age, as well as developmental screenings at 9, 18, and 30 months. Developmental screening seeks to identify problems or delays during normal childhood development. It includes questions about a child’s development, such as language, movement, thinking, behavior and emotions.
3. Data on Developmental Screening. Although developmental screening is required and mandated, it appears compliance may be low. DHCS reported in 2017 its data reflected only slightly more than a third of children receiving developmental screening. DHCS enumerated, based on its study, a number of barriers, including lack of education, referrals and resources, as well as inconsistent use of standardized tools and of the billing code signifying a developmental screen had occurred. A 2019 state audit on Medi-Cal delivery of preventive services to children found similarly low measures on a range of children’s preventive health care.
4. Governor’s 2019-20 Budget Proposal. The governor’s budget proposes three new programs funded with Proposition 56, a special fund created by proposition that raised tobacco tax revenues to fund health programs. One proposal is to allocate about $53 million of Proposition 56 to provide reimbursement for both developmental and trauma screenings for all children ages 0-21, as well as support trauma screenings for all adults with full-scope coverage in Medi-Cal. These screenings will be billed and reimbursed in both the managed care and fee-for-service delivery systems. These payments will be in addition to the amounts paid generally for the office visit in fee-for-service scenarios or capitation paid by managed care plans.

Another proposal uses Proposition 56 funds to create directed payment programs that Medi-Cal managed care health plans (MCPs) would be required to implement to provide value-based payments to providers who meet necessary criteria. One of the measures that could result in payment, according to the proposal, is an increase in the number of well-child visits infants and toddlers receive, as well as the preventive services associated with those visits, by incentivizing the latter visits in the series of well-child visits recommended by the American Academy of Pediatrics (AAP) between birth and 15 months of life. A total of $180 million GF ($360 million total funds) is proposed for this purpose.

1. Related Legislation. AB 741 (Kalra), also pending in this committee, contains several provisions intended to increase trauma screenings in the Medi-Cal program.

AB 537 (Wood), among other provisions, requires DHCS to develop a value-based financial incentive program to reward managed care plans that meet performance targets.

1. Prior Legislation. AB 11 (McCarty), of the 2017-18 Legislative Session, was similar to this bill in that it would have required screening services provided under EPSDT to include developmental screening services for individuals zero to three years of age and would have required the EQRO to review, survey and report on MCMC plan reporting and compliance with developmental screening requirements. AB 11 was vetoed by Governor Brown, who cited lack of necessity.

Analysis Prepared by: Lisa Murawski / APPR. / (916) 319-2081