Existing law establishes the Medi-Cal program, which is administered by the State Department of Health Care Services and under which qualified low-income individuals receive health care services through various health care delivery systems, including managed care pursuant to Medi-Cal managed care plan contracts. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions.

Existing law establishes, until January 1, 2026, certain time or distance and appointment time standards for specified Medi-Cal managed care covered services, consistent with federal regulations relating to network adequacy standards, to ensure that those services are available and accessible to enrollees of Medi-Cal managed care plans in a timely manner, as specified. Existing law sets forth various limits on the number of miles or minutes from the enrollees place of residence, depending on the type of service or specialty and, in some cases, on the county.

This bill would require the department, no later than January 1, 2025, to prepare and submit a report to the Legislature that includes certain information, including an analysis of the adequacy of each Medi-Cal managed care plans network for pediatric primary care, including the number and geographic distribution of providers and the plans compliance with the above-described time or distance and appointment time standards.

Under the bill, the report would also include data, disaggregated as specified, on the number of children and pregnant or postpartum persons who are Medi-Cal beneficiaries receiving certain health care services during the 202122, 202223, and 202324 fiscal years. The report would also include additional information regarding the departments efforts to improve access to pediatric preventive care, as specified. The bill would require that the report be made publicly available through its posting on the departments internet website.

The bill would repeal these reporting provisions on January 1, 2029.

Existing law establishes the Medi-Cal program, which is administered by the State Department of Health Care Services and under which qualified low-income individuals receive health care services through various health care delivery systems, including managed care pursuant to Medi-Cal managed care plan contracts. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions.

Existing law establishes, until January 1, 2026, certain time or distance and appointment time standards for specified Medi-Cal managed care covered services, consistent with federal regulations relating to network adequacy standards, to ensure that those services are available and accessible to enrollees of Medi-Cal managed care plans in a timely manner, as specified. Existing law sets forth various limits on the number of miles or minutes from the enrollees place of residence, depending on the type of service or specialty and, in some cases, on the county.

Existing law establishes the Medi-Cal program, which is administered by the State Department of Health Care Services and under which qualified low-income individuals receive health care services through various health care delivery systems, including managed care pursuant to Medi-Cal managed care plan contracts. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions.

Existing law establishes, until January 1, 2026, certain time or distance and appointment time standards for specified Medi-Cal managed care covered services, consistent with federal regulations relating to network adequacy standards, to ensure that those services are available and accessible to enrollees of Medi-Cal managed care plans in a timely manner, as specified. Existing law sets forth various limits on the number of miles or minutes from the enrollees place of residence, depending on the type of service or specialty and, in some cases, on the county.

Existing law authorizes a Medi-Cal managed care plan to use clinically appropriate video synchronous interaction as a means of demonstrating compliance with those standards. Existing law authorizes the department, upon request of a Medi-Cal managed care plan, to authorize alternative access standards for those standards under certain conditions, with the request being approved or denied on ZIP Code and provider type basis, as specified.

Existing law establishes the Medi-Cal program, which is administered by the State Department of Health Care Services and under which qualified low-income individuals receive health care services through various health care delivery systems, including managed care pursuant to Medi-Cal managed care plan contracts. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions.

Existing law establishes, until January 1, 2026, certain time or distance and appointment time standards for specified Medi-Cal managed care covered services, consistent with federal regulations relating to network adequacy standards, to ensure that those services are available and accessible to enrollees of Medi-Cal managed care plans in a timely manner, as specified. Existing law sets forth various limits on the number of miles or minutes from the enrollees place of residence, depending on the type of service or specialty and, in some cases, on the county.

Existing law authorizes a Medi-Cal managed care plan to use clinically appropriate video synchronous interaction as a means of demonstrating compliance with those standards. Existing law authorizes the department, upon request of a Medi-Cal managed care plan, to authorize alternative access standards for those standards under certain conditions, with the request being approved or denied on ZIP Code and provider type basis, as specified.

This bill would require the department to conduct an analysis to identify the number of Medi-Cal providers needed to ensure adequate access to childrens health care services, through compliance by Medi-Cal managed care plans with the above-described time or distance and appointment time standards across all service areas or counties of the state. The bill would require the department to prepare a report of the analysis and to submit the report to the Legislature no later than January 1, 2026. The bill would repeal the analysis and reporting provisions on January 1, 2030.

GOVERNOR'S VETO

GV Bill Id:AB 1202

Author:(Lackey)

As Enrolled Ver:September 18, 2023

2/3 vote

SUMMARY

Requires Medi-Cal managed care plans to produce an analysis of the adequacy of each Medi-Cal managed care plan's network for pediatric primary care, and the Medi-Cal managed care plan's compliance with the time or distance and appointment time standards, and requires the Department of Health Care Services (DHCS) to produce a related legislative report on progress in implementing steps to improve utilization of children's preventive services.

Senate Amendments

1. Recast the reporting requirement related to adequacy of pediatric providers in Medi-Cal managed care plans' networks.
2. Recast the reporting requirements for pediatric health care quality data.

Governor’s Veto Message

This bill would require the Department of Health Care Services (DHCS) to prepare a public report including information on each Medi-Cal managed care plan's network adequacy of pediatric primary care, data on beneficiaries, and reporting on DHCS' efforts to improve access.

I am a proponent of transparency; however, this bill's data collection and reporting requirements are largely duplicative of existing efforts. DHCS currently publicly reports on managed care and fee for service adequacy. Each year, DHCS also publishes a Health Disparities Report. Further, DHCS is currently developing the CalAIM dashboard, which will include additional data that aligns with what this bill calls for. The existing data that is available should be evaluated and leveraged before adding new administrative requirements.

COMMENTS

1. Children's Preventive Health Services in Medi-Cal. Access to pediatric providers for well-child visits is necessary for children to receive recommended preventive services, including screening assessments, vaccinations, developmental surveillance, risk factor reduction interventions, and other services. Medi-Cal covers periodic screening assessments for infants, children, and adolescents under 21 years of age, as specified in the American Academy of Pediatrics (AAP) Bright Futures® preventive healthcare periodicity schedule. The AAP Bright Futures® periodicity schedule provides clear, comprehensive guidance on recommended services at each well-child visit, corresponding to each age milestone up to age 21. For instance, it specifies developmental screening is recommended at well-child visits occurring at nine months, 18 months, and 30 months of age.

Children's preventive health care services are required to be provided by federal law, which establishes an entitlement to the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit. The EPSDT benefit provides a comprehensive array of prevention, diagnostic, and treatment services for individuals under the age of 21 who are enrolled in Medi-Cal. DHCS issued All-Plan Letter 19-010 in 2019 to clarify and provide guidance to Medi-Cal managed care plans on their obligations to provide preventive health services per the AAP Bright Futures® periodicity schedule, under EPSDT.

1. Time, Distance, and Appointment Time Standards. The vast majority of children enrolled in Medi-Cal receive services through a managed care plan. In order to ensure meaningful access to health care with a health plan network, state law establishes allowable time and distance standards between beneficiaries and providers of many health care services, which Medi-Cal managed care plans must meet. The standards require that a beneficiary travel no more than 10 miles or 30 minutes from the beneficiary's residence to reach a provider for primary care, including pediatric primary care. DHCS is authorized to grant exceptions to these standards under circumstances specified in law.
2. Bureau of State Audits (BSA) Audit. 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. BSA found, among other things, that an annual average of 2.4 million children enrolled in Medi-Cal do not receive all required preventive services, and that many of the state's children do not have adequate access to Medi-Cal providers who can deliver the required pediatric preventive services, due in part to low Medi-Cal reimbursement rates.

BSA made a number of recommendations to address low rates of children's preventive services, most of which DHCS agreed to implement. However, DHCS declined to implement one recommendation that is the subject of this bill. Specifically, the auditor recommended that DHCS identify where more Medi‑Cal providers are needed and request additional funding from the Legislature to increase the number of providers in those identified areas. DHCS indicated it does not plan to implement that recommendation, citing its belief that broader workforce recruitment is beyond DHCS' purview. DHCS's response is discussed further below.

On April 30, 2019, the Joint Legislative Audit Committee and Assembly Committee on Health held a joint hearing to review the audit report and the DHCS response. On November 4, 2019, the Assembly Committee on Health and Senate Committee on Health held a joint informational hearing to review findings and recommendations related to the audit, as well as the standard Six Month Auditee Implementation Progress Report.

1. Follow-Up Audit Findings. On September 3, 2022, the BSA issued a follow-up audit to the original 2019 audit, titled "Department of Health Care Services Is Still Not Doing Enough to Ensure That Children in Medi‑Cal Receive Preventive Health Services." The BSA found DHCS made progress in implementing the 2019 audit's recommendations, but it has yet to fully implement eight of the 14 recommendations, and many of DHCS's efforts to improve its oversight of health plans' provision of children's preventive services were placed on hold during the COVID-19 pandemic

The audit noted concerns related to DHCS doing limited outreach and not distributing outreach materials during the COVID-19 pandemic as well as continued concerns about the accuracy of provider directories. The audit also notes DHCS approved nearly 10,500 exceptions related to managed care time and distance standards for pediatric services in fiscal year 2020–21, according to an external reviewer.

1. DHCS Response to the September 2022 Audit; Current Efforts. As noted, DHCS fully implemented six of the audit recommendations and seven more recommendations are partially implemented.

In its response, the department cites a number of ongoing initiatives to improve children's health care in Medi-Cal. Some of the initiatives have been implemented and others are in development. DHCS notes the March 2022 Medi-Cal's "Strategy to Support Health and Opportunity for Children and Families" is a forward-looking policy agenda for children and families enrolled in Medi-Cal, intended to unify the common threads of existing and newly proposed child and family health initiatives, and solidify DHCS' accountability and oversight of children's services. A number of the strategies are supportive of ensuring continued focus on children's health and increasing utilization of children's preventive services.

For instance, BSA recommended DHCS provide clearer and more comprehensive information about children's preventive services in its written materials. In February 2023, DHCS released a consumer-tested outreach toolkit that includes brochures specific to Medi-Cal services for children and teens under EPSDT, known in California as Medi-Cal for Kids & Teens, that will be shared annually with beneficiaries, as well as a "Know Your Rights Guide" detailing what actions beneficiaries can take if they are denied services. On August 25, 2023, DHCS distributed these brochures via an informational mailing to Medi-Cal fee-for-service (FFS) members and/or their parents or guardians.

In its response to the 2022 BSA audit recommendation that DHCS should identify the number of providers needed to ensure access, DHCS again indicated it does not have jurisdiction to address workforce issues and does not plan to implement the recommendation. However, DHCS indicates it plans to have an external evaluator conduct an access assessment by reviewing the various components of access, comparing managed care plan networks and access to care with commercial and Medicare Advantage markets. Through the assessment, DHCS aims to compare access in Medi-Cal managed care to access for Californians who receive health coverage through the commercial or Medicare Advantage markets. DHCS explains this will allow it to assess if any barriers to access are a reflection of systematic problems across the entire health care system—such as issues related to workforce pipeline – or if access barriers are specific to Medi-Cal. In addition, the assessment will track different levels of access to help determine whether issues exist at the managed care level (network adequacy), provider level (scheduling practices, responsiveness to member scheduling requests, etc.) or both. DHCS indicates the results of the assessment will be shared with the Centers for Medicare & Medicaid Services in March 2026.

The reporting required by this bill is not in conflict with the planned analysis, but will provide an assessment of the number and location of providers needed, which is intended to help the Legislature target workforce investments specifically to improve access to children's health care.

According to the Author

In response to a follow-up audit by BSA examining low rates of children's preventive health care utilization in Medi-Cal, this bill is intended to require DHCS to provide actionable information about how many pediatric providers are needed in order for Medi-Cal managed care plans to comply with network adequacy and access standards for pediatric care, for children enrolled in Medi-Cal. The author indicates this information would be useful to allow the Legislature to target resources to augment the pediatric health care workforce in areas of needed.

Arguments in Support

The Children's Partnership and health providers support this bill. Supporters argue this bill will help the state identify where more Medi-Cal providers are needed and request additional funding from the Legislature to increase the number of providers in those identified areas, as recommended by the BSA.

Arguments in Opposition

The Department of Finance is opposed to this bill, noting it results in General Fund impacts not included in the 2023 Budget.

FISCAL COMMENTS

According to the Senate Committee Appropriations, DHCS estimates costs of $612,000 in 2024-25 and $576,000 in 2025-26 (50% General Fund, 50% federal funds) for staffing resources to develop the data collection and analysis process necessary for the report.

VOTES

ASM HEALTH: 14-0-1

YES: Wood, Waldron, Aguiar-Curry, Arambula, Boerner Horvath, Flora, Vince Fong, Maienschein, McCarty, Joe Patterson, Rodriguez, Santiago, Villapudua, Weber

ABS, ABST OR NV: Wendy Carrillo

ASM APPROPRIATIONS: 15-0-1

YES: Holden, Megan Dahle, Bryan, Calderon, Wendy Carrillo, Dixon, Mike Fong, Hart, Lowenthal, Mathis, Papan, Pellerin, Sanchez, Weber, Ortega

ABS, ABST OR NV: Robert Rivas

ASSEMBLY FLOOR: 79-0-1

YES: Addis, Aguiar-Curry, Alanis, Alvarez, Arambula, Bains, Bauer-Kahan, Bennett, Berman, Boerner, Bonta, Bryan, Calderon, Juan Carrillo, Wendy Carrillo, Cervantes, Chen, Connolly, Megan Dahle, Davies, Dixon, Essayli, Flora, Mike Fong, Vince Fong, Friedman, Gallagher, Garcia, Gipson, Grayson, Haney, Hart, Holden, Hoover, Irwin, Jackson, Jones-Sawyer, Kalra, Lackey, Lee, Low, Lowenthal, Maienschein, Mathis, McCarty, McKinnor, Muratsuchi, Stephanie Nguyen, Ortega, Pacheco, Papan, Jim Patterson, Joe Patterson, Pellerin, Petrie-Norris, Quirk-Silva, Ramos, Reyes, Luz Rivas, Robert Rivas, Rodriguez, Blanca Rubio, Sanchez, Santiago, Schiavo, Soria, Ta, Ting, Valencia, Villapudua, Waldron, Wallis, Ward, Weber, Wicks, Wilson, Wood, Zbur, Rendon

ABS, ABST OR NV: Gabriel

SENATE FLOOR: 39-0-1

YES: Allen, Alvarado-Gil, Archuleta, Ashby, Atkins, Becker, Blakespear, Bradford, Cortese, Dahle, Dodd, Durazo, Eggman, Glazer, Gonzalez, Grove, Hurtado, Jones, Laird, Limón, McGuire, Menjivar, Min, Newman, Nguyen, Niello, Ochoa Bogh, Padilla, Portantino, Roth, Rubio, Seyarto, Skinner, Smallwood-Cuevas, Stern, Umberg, Wahab, Wiener, Wilk

ABS, ABST OR NV: Caballero

ASSEMBLY FLOOR: 78-0-2

YES: Addis, Aguiar-Curry, Alanis, Alvarez, Arambula, Bains, Bennett, Berman, Boerner, Bonta, Bryan, Calderon, Juan Carrillo, Wendy Carrillo, Cervantes, Connolly, Megan Dahle, Davies, Dixon, Essayli, Flora, Mike Fong, Vince Fong, Friedman, Gabriel, Gallagher, Garcia, Gipson, Grayson, Haney, Hart, Holden, Hoover, Irwin, Jackson, Jones-Sawyer, Kalra, Lackey, Lee, Low, Lowenthal, Maienschein, Mathis, McCarty, McKinnor, Muratsuchi, Stephanie Nguyen, Ortega, Pacheco, Papan, Jim Patterson, Joe Patterson, Pellerin, Petrie-Norris, Quirk-Silva, Ramos, Rendon, Reyes, Luz Rivas, Rodriguez, Blanca Rubio, Sanchez, Santiago, Schiavo, Soria, Ta, Ting, Valencia, Villapudua, Waldron, Wallis, Ward, Weber, Wicks, Wilson, Wood, Zbur, Robert Rivas

ABS, ABST OR NV: Bauer-Kahan, Chen

UPDATED

VERSION: September 18, 2023

CONSULTANT: Lisa Murawski / HEALTH / (916) 319-2097 FN: 0002543

CONCURRENCE IN SENATE AMENDMENTS

CSA1 Bill Id:AB 1202

Author:(Lackey)

As Amended Ver:July 13, 2023

Majority vote

SUMMARY

Requires Medi-Cal managed care plans to produce an analysis of the adequacy of each Medi-Cal managed care plan's network for pediatric primary care, and the Medi-Cal managed care plan’s compliance with the time or distance and appointment time standards, and requires the Department of Health Care Services (DHCS) to produce a related legislative report on progress in implementing steps to improve utilization of children's preventive services.

Senate Amendments

1. Recast the reporting requirement related to adequacy of pediatric providers in Medi-Cal managed care plans' networks.
2. Recast the reporting requirements for pediatric health care quality data.

COMMENTS

1. Children's Preventive Health Services in Medi-Cal. Access to pediatric providers for well-child visits is necessary for children to receive recommended preventive services, including screening assessments, vaccinations, developmental surveillance, risk factor reduction interventions, and other services. Medi-Cal covers periodic screening assessments for infants, children, and adolescents under 21 years of age, as specified in the American Academy of Pediatrics (AAP) Bright Futures® preventive healthcare periodicity schedule. The AAP Bright Futures® periodicity schedule provides clear, comprehensive guidance on recommended services at each well-child visit, corresponding to each age milestone up to age 21. For instance, it specifies developmental screening is recommended at well-child visits occurring at nine months, 18 months, and 30 months of age.

Children's preventive health care services are required to be provided by federal law, which establishes an entitlement to the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit. The EPSDT benefit provides a comprehensive array of prevention, diagnostic, and treatment services for individuals under the age of 21 who are enrolled in Medi-Cal. DHCS issued All-Plan Letter 19-010 in 2019 to clarify and provide guidance to Medi-Cal managed care plans on their obligations to provide preventive health services per the AAP Bright Futures® periodicity schedule, under EPSDT.

1. Time, Distance, and Appointment Time Standards. The vast majority of children enrolled in Medi-Cal receive services through a managed care plan. In order to ensure meaningful access to health care with a health plan network, state law establishes allowable time and distance standards between beneficiaries and providers of many health care services, which Medi-Cal managed care plans must meet. The standards require that a beneficiary travel no more than 10 miles or 30 minutes from the beneficiary's residence to reach a provider for primary care, including pediatric primary care. DHCS is authorized to grant exceptions to these standards under circumstances specified in law.
2. Bureau of State Audits (BSA) Audit. 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. BSA found, among other things, that an annual average of 2.4 million children enrolled in Medi-Cal do not receive all required preventive services, and that many of the state's children do not have adequate access to Medi-Cal providers who can deliver the required pediatric preventive services, due in part to low Medi-Cal reimbursement rates.

BSA made a number of recommendations to address low rates of children's preventive services, most of which DHCS agreed to implement. However, DHCS declined to implement one recommendation that is the subject of this bill. Specifically, the auditor recommended that DHCS identify where more Medi‑Cal providers are needed and request additional funding from the Legislature to increase the number of providers in those identified areas. DHCS indicated it does not plan to implement that recommendation, citing its belief that broader workforce recruitment is beyond DHCS' purview. DHCS's response is discussed further below.

On April 30, 2019, the Joint Legislative Audit Committee and Assembly Committee on Health held a joint hearing to review the audit report and the DHCS response. On November 4, 2019, the Assembly Committee on Health and Senate Committee on Health held a joint informational hearing to review findings and recommendations related to the audit, as well as the standard Six Month Auditee Implementation Progress Report.

1. Follow-Up Audit Findings. On September 3, 2022, the BSA issued a follow-up audit to the original 2019 audit, titled "Department of Health Care Services Is Still Not Doing Enough to Ensure That Children in Medi‑Cal Receive Preventive Health Services." The BSA found DHCS made progress in implementing the 2019 audit's recommendations, but it has yet to fully implement eight of the 14 recommendations, and many of DHCS's efforts to improve its oversight of health plans' provision of children's preventive services were placed on hold during the COVID-19 pandemic

The audit noted concerns related to DHCS doing limited outreach and not distributing outreach materials during the COVID-19 pandemic as well as continued concerns about the accuracy of provider directories. The audit also notes DHCS approved nearly 10,500 exceptions related to managed care time and distance standards for pediatric services in fiscal year 2020–21, according to an external reviewer.

1. DHCS Response to the September 2022 Audit; Current Efforts. As noted, DHCS fully implemented six of the audit recommendations and seven more recommendations are partially implemented.

In its response, the department cites a number of ongoing initiatives to improve children's health care in Medi-Cal. Some of the initiatives have been implemented and others are in development. DHCS notes the March 2022 Medi-Cal's "Strategy to Support Health and Opportunity for Children and Families" is a forward-looking policy agenda for children and families enrolled in Medi-Cal, intended to unify the common threads of existing and newly proposed child and family health initiatives, and solidify DHCS' accountability and oversight of children's services. A number of the strategies are supportive of ensuring continued focus on children's health and increasing utilization of children's preventive services.

For instance, BSA recommended DHCS provide clearer and more comprehensive information about children's preventive services in its written materials. In February 2023, DHCS released a consumer-tested outreach toolkit that includes brochures specific to Medi-Cal services for children and teens under EPSDT, known in California as Medi-Cal for Kids & Teens, that will be shared annually with beneficiaries, as well as a "Know Your Rights Guide" detailing what actions beneficiaries can take if they are denied services. On August 25, 2023, DHCS distributed these brochures via an informational mailing to Medi-Cal fee-for-service (FFS) members and/or their parents or guardians.

In its response to the 2022 BSA audit recommendation that DHCS should identify the number of providers needed to ensure access, DHCS again indicated it does not have jurisdiction to address workforce issues and does not plan to implement the recommendation. However, DHCS indicates it plans to have an external evaluator conduct an access assessment by reviewing the various components of access, comparing managed care plan networks and access to care with commercial and Medicare Advantage markets. Through the assessment, DHCS aims to compare access in Medi-Cal managed care to access for Californians who receive health coverage through the commercial or Medicare Advantage markets. DHCS explains this will allow it to assess if any barriers to access are a reflection of systematic problems across the entire health care system—such as issues related to workforce pipeline – or if access barriers are specific to Medi-Cal. In addition, the assessment will track different levels of access to help determine whether issues exist at the managed care level (network adequacy), provider level (scheduling practices, responsiveness to member scheduling requests, etc.) or both. DHCS indicates the results of the assessment will be shared with the Centers for Medicare & Medicaid Services in March 2026.

The reporting required by this bill is not in conflict with the planned analysis, but will provide an assessment of the number and location of providers needed, which is intended to help the Legislature target workforce investments specifically to improve access to children's health care.

According to the Author

In response to a follow-up audit by BSA examining low rates of children's preventive health care utilization in Medi-Cal, this bill is intended to require DHCS to provide actionable information about how many pediatric providers are needed in order for Medi-Cal managed care plans to comply with network adequacy and access standards for pediatric care, for children enrolled in Medi-Cal. The author indicates this information would be useful to allow the Legislature to target resources to augment the pediatric health care workforce in areas of needed.

Arguments in Support

The Children's Partnership and health providers support this bill. Supporters argue this bill will help the state identify where more Medi-Cal providers are needed and request additional funding from the Legislature to increase the number of providers in those identified areas, as recommended by the BSA.

Arguments in Opposition

The Department of Finance is opposed to this bill, noting it results in General Fund impacts not included in the 2023 Budget.

FISCAL COMMENTS

According to the Senate Committee Appropriations, DHCS estimates costs of $612,000 in 2024-25 and $576,000 in 2025-26 (50% General Fund, 50% federal funds) for staffing resources to develop the data collection and analysis process necessary for the report.

VOTES:

ASM HEALTH: 14-0-1

YES: Wood, Waldron, Aguiar-Curry, Arambula, Boerner Horvath, Flora, Vince Fong, Maienschein, McCarty, Joe Patterson, Rodriguez, Santiago, Villapudua, Weber

ABS, ABST OR NV: Wendy Carrillo

ASM APPROPRIATIONS: 15-0-1

YES: Holden, Megan Dahle, Bryan, Calderon, Wendy Carrillo, Dixon, Mike Fong, Hart, Lowenthal, Mathis, Papan, Pellerin, Sanchez, Weber, Ortega

ABS, ABST OR NV: Robert Rivas

ASSEMBLY FLOOR: 79-0-1

YES: Addis, Aguiar-Curry, Alanis, Alvarez, Arambula, Bains, Bauer-Kahan, Bennett, Berman, Boerner, Bonta, Bryan, Calderon, Juan Carrillo, Wendy Carrillo, Cervantes, Chen, Connolly, Megan Dahle, Davies, Dixon, Essayli, Flora, Mike Fong, Vince Fong, Friedman, Gallagher, Garcia, Gipson, Grayson, Haney, Hart, Holden, Hoover, Irwin, Jackson, Jones-Sawyer, Kalra, Lackey, Lee, Low, Lowenthal, Maienschein, Mathis, McCarty, McKinnor, Muratsuchi, Stephanie Nguyen, Ortega, Pacheco, Papan, Jim Patterson, Joe Patterson, Pellerin, Petrie-Norris, Quirk-Silva, Ramos, Reyes, Luz Rivas, Robert Rivas, Rodriguez, Blanca Rubio, Sanchez, Santiago, Schiavo, Soria, Ta, Ting, Valencia, Villapudua, Waldron, Wallis, Ward, Weber, Wicks, Wilson, Wood, Zbur, Rendon

ABS, ABST OR NV: Gabriel

UPDATED

VERSION: July 13, 2023

CONSULTANT: Lisa Murawski / HEALTH / (916) 319-2097 FN: 0001726

 THIRD READING  

Bill No: AB 1202

Author: Lackey (R), et al.

Amended: 7/13/23 in Senate

Vote: 21

SENATE HEALTH COMMITTEE: 11-0, 7/12/23

AYES: Eggman, Nguyen, Glazer, Gonzalez, Hurtado, Limón, Menjivar, Roth, Rubio, Wahab, Wiener

NO VOTE RECORDED: Grove

SENATE APPROPRIATIONS COMMITTEE: 7-0, 9/1/23

AYES: Portantino, Jones, Ashby, Bradford, Seyarto, Wahab, Wiener

ASSEMBLY FLOOR: 79-0, 5/31/23 - See last page for vote

SUBJECT: Medi-Cal: health care services data: children and pregnant or postpartum persons

SOURCE: The Children’s Partnership

DIGEST:

This bill requires the Department of Health Care Services (DHCS) to prepare a report to the Legislature that includes information and analysis on the adequacy of each Medi-Cal managed care (MCMC) plan’s network for pediatric primary care, including the number and geographic distribution of providers and the plan’s compliance with established time or distance and appointment-time standards no later than January 1, 2025. This bill requires the report to include disaggregated data on the number of children and pregnant or postpartum persons who are Medi-Cal beneficiaries receiving various preventative, primary and behavioral healthcare services; information on DHCS’s efforts to improve access to pediatric preventive care; and to be posted on DHCS’s website.

ANALYSIS: Existing federal law requires state Medicaid plans to cover any clinical preventive services that are assigned a grade of A or B by the United States Preventive Services Task Force. Also requires coverage for individuals under age 21 of all necessary 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, whether or not such services are covered under the State plan, known as the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) benefit. [42 USC §1396d]

Existing state law:

1. Establishes the Medi-Cal program, administered by DHCS, under which low-income individuals are eligible for medical coverage. [Welfare & Institutions Code (WIC) §14000, et seq.]
2. Establishes a schedule of benefits under the Medi-Cal program, which includes benefits required under federal law and benefits provided at state option but for which federal financial participation through Medicaid is available. The schedule of benefits includes EPSDT for individuals under 21 years of age. [WIC §14132]
3. Requires MCMC plans to include developmental screening services for individuals zero to three years of age, inclusive, that comply with the periodicity schedule and standardized and validated developmental screening tools established by the Bright Future Guidelines and Recommendations for Preventive Pediatric Care. [WIC §14132.195]
4. Requires a MCMC plan to maintain a network of providers that are located within specified time and distance standards for specified services. Establishes time or distance standards for primary care as ten miles or 30 minutes from the beneficiary’s place of residence. [WIC §14197]
5. Allows DHCS, upon request of a MCMC plan, to authorize alternative access standards for the established time or distance standards if the MCMC plan has exhausted all other reasonable options to obtain providers to meet the applicable standard or the MCMC plan’s delivery structure is capable of delivering the appropriate level of care and access. [WIC §14197]

This bill requires DHCS to prepare and submit a report to the Legislature no later than January 1, 2025, and to post the report on its website. Requires the report to include all of the following:

1. An analysis of the adequacy of each MCMC plan’s network for pediatric primary care, including the number and geographic distribution of providers and the MCMC plan’s compliance with the time or distance and appointment time standards in existing state law. In providing this analysis, DHCS is encouraged to use reports that are obtained to meet the Terms and Conditions of the approved CalAIM 1915(b) waiver.
2. Data on the following populations and services, broken down by racial or ethnic groups, primary language spoken, county, and relevant age group:
   1. For the 2021–22, 2022–23, and 2023–24 fiscal years, the number of children who are Medi-Cal beneficiaries receiving any of the early childhood preventive or developmental services listed, disaggregated by age-related cohort and by service type: six or more well-child visits in the first 15 months of life; well-child visits in the third, fourth, fifth, and sixth years of life; child and adolescent well-care visits; immunizations; developmental screenings in the first three years of life; weight assessment and nutrition and physical activity counseling; lead screening; screening for depression for children 12 to 17 years of age, inclusive; annual dental visit; and, preventive dental services in the last year.
   2. For the 2021–22, 2022–23, and 2023–24 fiscal years, the number of children who are Medi-Cal beneficiaries who accessed primary care practitioners during the fiscal year, broken down by the following age groups:
      1. 12 to 24 months of age, inclusive;
      2. 25 months to 6 years of age, inclusive;
      3. 7 to 11 years of age, inclusive; and,
      4. 12 to 19 years of age, inclusive.
   3. For the 2021–22, 2022–23, and 2023–24 fiscal years, the number of pregnant persons, and the number of postpartum persons, who are Medi-Cal beneficiaries receiving any of the following services, disaggregated by pregnancy or postpartum status and by service type:
      1. Depression or suicide risk screenings. Depression screenings may include maternal depression screenings;
      2. Tobacco, alcohol, or drug use assessments.
3. Additional information regarding the department’s efforts to improve access to pediatric preventive care, including all of the following:
   1. Specific steps that the department has taken to hold MCMC plans accountable for improving utilization of children’s preventive services, including, but not limited to, monitoring the efficacy of MCMC plan activities through Healthcare Effectiveness Data and Information Set (HEDIS) measures and MCMC plan requirements related to the Population Health Management Program, as specific to children’s preventive care.
   2. Evidence of progress in reducing racial and ethnic disparities for well-child visits and immunizations for children served by the Medi-Cal program.
   3. Evidence of MCMC plan compliance with contractual requirements to train providers on EPSDT requirements, and the number of providers trained.
   4. Level of accuracy of MCMC plan provider directories, based on the most recent available results of provider directory validation.

Comments

1. Author’s statement. According to the author, this bill represents an important step toward providing millions of California children as well as pregnant and postpartum individuals with access to critical care that is necessary to prevent life-long and life-threatening illness and disease. Our state’s most vulnerable populations are receiving a fraction of the services they are entitled to as a MCMC plan beneficiary, often as a result of provider shortages leading to significant wait times or far distances that a family would have to travel for an appointment. By working with DHCS and MCMC plans to identify how many providers are necessary to meet time and distance standards, we can get to work on solving these provider shortages and ensuring that everyone has access to high-quality care options.
2. Children’s preventive services in Medi-Cal. Medi-Cal includes a very comprehensive pediatric preventive services mandate stemming from federal EPSDT requirement and the Affordable Care Act preventive care requirement.
3. EPSDT. 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 (CMS). According to CMS, the EPSDT benefit is more robust than the Medicaid benefit for adults and is designed to assure that children receive early detection and care, so that health problems are averted or diagnosed and treated as early as possible. The goal of EPSDT is to assure that individual children get the health care they need when they need it—the right care to the right child at the right time in the right setting. 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. All MCMC plans must provide EPSDT preventive services, including screenings, designed to identify health and developmental issues as early as possible. MCMC plans must provide plan enrollees with appropriate referrals for diagnosis and treatment without delay.
4. The Affordable Care Act 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), an agency of the U.S. Department of Health and Human Services. 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 American Academy of Pediatrics (AAP). The AAP develops theory-based and evidence-based 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 periodicity schedule indicates specific preventive screenings and procedures that are to be provided to children at age-specific periodic intervals from birth through age 21. MCMC plans are required to use the current Bright Futures periodicity schedule and guidelines for enrollees under age 21, including health and developmental screening services, physical examination, dental services, vision services, and hearing services. MCMC plans must provide all age-specific assessments and services required by the MCMC plan contract and the Bright Futures periodicity schedule.
5. 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. The audit included the following key findings:
6. Lack of awareness about available preventive services. The audit found that there was a lack of awareness about the availability of preventive services for families and a lack awareness by MCMC plans that children should be receiving mandatory preventive services. One of the auditor’s recommendations to address this issue was for DHCS to provide to the families of eligible children clearer and more comprehensive information about those services. DHCS released an updated draft of the Evidence of Coverage (EOC) that makes clearer preventive services offered under the EPSDT program in 2019;
7. Access and utilization. The audit found that DHCS requires MCMC plans to report on performance measures for only a portion of the required preventive services. Utilization rates were higher in that portion of services that require reporting. To improve access and utilization rates, the audit recommended that DHCS establish by March 2020 performance measures that cover children’s preventive 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 both the CMS child and adult 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 MCMC plans. DHCS contracts with an external quality review organization 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. DHCS also agreed to increase MCMC plan sanctions, as appropriate, so that it may take quicker punitive action when MCMC plans are found out of compliance; and,
8. Alternative access standards. The auditor’s report found children’s access to preventive care shows notable deficiencies with respect to both the number and location of providers who offer children’s preventive services. CMS’s 2016 Managed Care Final Rule (final rule) required the state to develop and enforce new time and distance standards for access to providers. AB 205 (Wood, Chapter 738, Statutes of 2017) established standards for how long, or how far, beneficiaries should have to travel to have access to primary care providers and specialists. MCMC plans who cannot meet those standards can request and receive approval for an alternative access standard.

According to DHCS, there was a total of 182,000 possible alternative access standard requests that could have been submitted. MCMC plans actually submitted nearly 80,000 requests, although DHCS indicates some of those requests were duplicates. DHCS approved nearly 10,000 of those requests. Fifty-two counties had at least one alternative access request approved in their county. Some of the alternative access standards reflect the difficulty in finding a specialist in a rural area. For instance, some families in Mono County may have to travel almost nine hours, or 365 miles, to see a pediatric dermatologist instead of the 90 minutes and 60 miles permitted under the original access standards. There also remains challenges in access to primary care. In San Bernardino County, some families may have to travel nearly two hours, or 70 miles, to see a pediatric primary care physician instead of the 30 minutes and ten miles permitted under the original access standards. The auditor’s report noted that MCMC plans with more alternative access requests had lower rates of utilization for children’s preventive services.

The implementation of the alternative access standards has led to children in many parts of the state with limited access to care. DHCS’ procedure for reviewing alternative access standards requests includes determining whether the proposed alternative standard is reasonable. The auditor’s report questions whether some of the approved alternative standards were reasonable, and suggests that rather than approving such extreme standards, DHCS could require MCMC plans to provide out-of-network access in such situations.

1. September 2022 follow up report to the 2019 audit. Recently the State Auditor issued a follow up report to the 2019 audit finding that DHCS has been unsuccessful in increasing the percentage of children receiving the preventive services required by Medi‑Cal. From fiscal years 2018–19 through 2020–21, DHCS continued to provide these services to less than half of the children in Medi‑Cal, leaving an average of 2.9 million children per year missing at least some preventive services. The number of children in Medi‑Cal who received preventive care decreased during the COVID-19 pandemic. In fiscal year 2020–21, less than 42% of children received the required number of preventive services, which compared to a pre-pandemic level of almost 48% in fiscal year 2018–19. The percentage of children in Medi‑Cal receiving the required amounts of preventive care continued to be even lower among certain age groups during the most recent three fiscal years. For example, nearly three quarters of two-year-olds in Medi‑Cal did not receive the required number of preventive services, which includes blood lead testing and screening for developmental disorders. The follow up report also found in the more than three years since its initial recommendations were issued, DHCS fully implemented just six of the 14 recommendations. The report specifically called out DHCS’s failure to distribute outreach materials during the pandemic, failure to ensure that provider directories were accurate, and failure to increase the number of providers available.

DHCS responded, agreeing with seven of the remaining eight recommendations that had not been fully implemented, indicating steps they were taking to meet those recommendations. On the eighth recommendation to identify the number of providers needed to ensure adequate access, DHCS denied responsibility, stating that workforce issues were not within their jurisdiction. DHCS also pointed to a number of ongoing initiatives intended to improve children’s access to health care services in Medi-Cal, some of which are still in development.

This bill aims to follow up on the outstanding issues regarding children’s access to providers and preventive services by requesting: 1) a network adequacy analysis of pediatric providers; 2) a report including that analysis and other steps DHCS has taken to oversee MCMC plan requirements regarding children’s preventive services; and, 3) a report on the number of children and pregnant and postpartum women receiving specific preventive services.

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

According to the Senate Appropriations Committee, DHCS estimates costs of $612,000 in 2024-25 and $576,000 in 2025-26 (50 percent General Fund, 50 percent federal funds) for staffing resources to develop the data collection and analysis process necessary for the report.

SUPPORT: (Verified 9/1/23)

The Children’s Partnership (source)

California Association for Health Services at Home

California Hospital Association

California Optometric Association

California Pan-Ethnic Health Network

Children’s Bureau of Southern California

Depression and Bipolar Support Alliance California
National Health Law Program

The Los Angeles Trust for Children’s Health

Western Center on Law & Poverty

OPPOSITION: (Verified 9/1/23)

Department of Finance

ARGUMENTS IN SUPPORT: This bill’s sponsor, The Children’s Partnership, writes that this bill helps the state identify where more Medi-Cal providers are needed in order to increase the number of providers in those identified areas. It would bring California one step closer to providing equitable access to quality health care for the approximately 5.5 million children in California who receive medical care through Medi-Cal. Children covered by Medicaid programs are more likely to be born with low birth weights or have developmental delays, learning disorders, or other medical conditions requiring quality health care. The California State Auditor found that DHCS is providing less than half of the children on Medi-Cal with prevention services, which means an average of 2.9 million children are missing some of these essential services. Investments in quality early identification and intervention saves money in the long-term by reducing or eliminating the costs of special education services, repetition, child welfare, and juvenile justice.

ARGUMENTS IN OPPOSITION: The Department of Finance is opposed to this bill because it results in General Fund impacts not included in the 2023 Budget.

ASSEMBLY FLOOR: 79-0, 5/31/23

AYES: Addis, Aguiar-Curry, Alanis, Alvarez, Arambula, Bains, Bauer-Kahan, Bennett, Berman, Boerner, Bonta, Bryan, Calderon, Juan Carrillo, Wendy Carrillo, Cervantes, Chen, Connolly, Megan Dahle, Davies, Dixon, Essayli, Flora, Mike Fong, Vince Fong, Friedman, Gallagher, Garcia, Gipson, Grayson, Haney, Hart, Holden, Hoover, Irwin, Jackson, Jones-Sawyer, Kalra, Lackey, Lee, Low, Lowenthal, Maienschein, Mathis, McCarty, McKinnor, Muratsuchi, Stephanie Nguyen, Ortega, Pacheco, Papan, Jim Patterson, Joe Patterson, Pellerin, Petrie-Norris, Quirk-Silva, Ramos, Reyes, Luz Rivas, Robert Rivas, Rodriguez, Blanca Rubio, Sanchez, Santiago, Schiavo, Soria, Ta, Ting, Valencia, Villapudua, Waldron, Wallis, Ward, Weber, Wicks, Wilson, Wood, Zbur, Rendon

NO VOTE RECORDED: Gabriel

Prepared by: Jen Flory / HEALTH / (916) 651-4111

9/5/23 9:42:36

**** END ****

SENATE COMMITTEE ON

Senator Anthony Portantino, Chair

2023 - 2024 Regular Session

AB 1202 (Lackey) - Medi-Cal: health care services data: children and pregnant or postpartum persons

Bill Summary:

AB 1202 would require the Department of Health Care Services (DHCS) to submit a report to the Legislature that includes information regarding access to pediatric preventive care in the Medi-Cal program, as specified.

Fiscal Impact:

The DHCS estimates costs of $612,000 in 2024-25 and $576,000 in 2025-26 (50 percent General Fund, 50 percent federal funds) for staffing resources to develop the data collection and analysis process necessary for the report.

Background:

The DHCS administers the Medi-Cal program which provides medical coverage to eligible low-income individuals. Existing law requires Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) benefit coverage for individuals under age 21 of all necessary 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, as specified.

Current law requires a Medi-Cal managed care (MCMC) plan to maintain a network of providers that are located within specified time and distance standards for specified services, and establishes time or distance standards for primary care as ten miles or 30 minutes from the beneficiary’s place of residence. The DHCS may, upon request of a MCMC plan, authorize alternative access standards for the established time or distance standards if the MCMC plan has exhausted all other reasonable options to obtain providers to meet the applicable standard or the MCMC plan’s delivery structure is capable of delivering the appropriate level of care and access.

Proposed Law:

AB 1202 would require, no later than January 1, 2025, the DHCS to submit a report to the Legislature that includes the following:

• An analysis of the adequacy of each MCMC’s network for pediatric primary care, including the number and geographic distribution of providers and the MCMC’s compliance with the time or distance and appointment time standards, as specified.
• Data on specified populations and services, broken down by racial or ethnic groups, primary language spoken, county, and relevant age group.
• Additional information regarding the DHCS’s efforts to improve access to pediatric preventive care, as specified.

-- END --

SENATE COMMITTEE ON

Senator Anthony Portantino, Chair

2023 - 2024 Regular Session

AB 1202 (Lackey) - Medi-Cal: health care services data: children and pregnant or postpartum persons

Bill Summary:

AB 1202 would require the Department of Health Care Services (DHCS) to submit a report to the Legislature that includes information regarding access to pediatric preventive care in the Medi-Cal program, as specified.

Fiscal Impact:

The DHCS estimates costs of $612,000 in 2024-25 and $576,000 in 2025-26 (50 percent General Fund, 50 percent federal funds) for staffing resources to develop the data collection and analysis process necessary for the report.

Background:

The DHCS administers the Medi-Cal program which provides medical coverage to eligible low-income individuals. Existing law requires Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) benefit coverage for individuals under age 21 of all necessary 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, as specified.

Current law requires a Medi-Cal managed care (MCMC) plan to maintain a network of providers that are located within specified time and distance standards for specified services, and establishes time or distance standards for primary care as ten miles or 30 minutes from the beneficiary’s place of residence. The DHCS may, upon request of a MCMC plan, authorize alternative access standards for the established time or distance standards if the MCMC plan has exhausted all other reasonable options to obtain providers to meet the applicable standard or the MCMC plan’s delivery structure is capable of delivering the appropriate level of care and access.

Proposed Law:

AB 1202 would require, no later than January 1, 2025, the DHCS to submit a report to the Legislature that includes the following:

• An analysis of the adequacy of each MCMC’s network for pediatric primary care, including the number and geographic distribution of providers and the MCMC’s compliance with the time or distance and appointment time standards, as specified.
• Data on specified populations and services, broken down by racial or ethnic groups, primary language spoken, county, and relevant age group.
• Additional information regarding the DHCS’s efforts to improve access to pediatric preventive care, as specified.

-- END --

SENATE COMMITTEE ON HEALTH

Senator Dr. Susan Talamantes Eggman, Chair

BILL NO: AB 1202

SUBJECT: Medi-Cal: time or distance standards: children’s health care services

SUMMARY:

1. Requires each Medi-Cal managed care (MCMC) plan to conduct and report to the Department of Health Care Services (DHCS) the results of a network adequacy analysis for pediatric primary care no later than January 1, 2025. Requires DHCS to submit a report to the Legislature information from the network adequacy analysis and other specified information, including specific steps DHCS has taken to hold MCMC plans accountable for improving utilization of children’s preventive services no later than January 1, 2026. Requires DHCS to submit a report to the Legislature on specified data regarding the number of children receiving specified preventive services and the number of pregnant or postpartum persons receiving specified services no later than July 1, 2024.

Existing federal law

Requires state Medicaid plans to cover any clinical preventive services that are assigned a grade of A or B by the United States Preventive Services Task Force. Also requires coverage for individuals under age 21 of all necessary 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, whether or not such services are covered under the State plan, known as the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) benefit. [42 USC §1396d]

Existing state law:

1. Establishes the Medi-Cal program, administered by DHCS, under which low-income individuals are eligible for medical coverage. [WIC §14000, et seq.]
2. Establishes a schedule of benefits under the Medi-Cal program, which includes benefits required under federal law and benefits provided at state option but for which federal financial participation through Medicaid is available. The schedule of benefits includes EPSDT for individuals under 21 years of age. [WIC §14132]
3. Requires MCMC plans to include developmental screening services for individuals zero to three years of age, inclusive, that comply with the periodicity schedule and standardized and validated developmental screening tools established by the Bright Future Guidelines and Recommendations for Preventive Pediatric Care. [WIC §14132.195]
4. Requires a MCMC plan to maintain a network of providers that are located within specified time and distance standards for specified services. Establishes time or distance standards for primary care as ten miles or 30 minutes from the beneficiary’s place of residence. [WIC §14197]
5. Allows DHCS, upon request of a MCMC plan, to authorize alternative access standards for the established time or distance standards if the MCMC plan has exhausted all other reasonable options to obtain providers to meet the applicable standard or the MCMC plan’s delivery structure is capable of delivering the appropriate level of care and access. [WIC §14197]

This bill:

1. Requires each MCMC plan to conduct and report to DHCS the results of an analysis to identify the number and, as appropriate, the geographic distribution of Medi-Cal providers needed to ensure the MCMC plan’s compliance with the existing time or distance and appointment time standards for pediatric primary care, across all service areas of the plan, no later than January 1, 2025.
2. Requires DHCS to prepare and submit a report to the Legislature, no later than January 1, 2026, that includes all of the following:
3. A summary of the results of the analysis in 1) above reported by MCMC plans;
4. Specific steps that DHCS has taken to hold MCMC plans accountable for improving utilization of children’s preventive services, including:
5. Monitoring the efficacy of MCMC plan activities through Healthcare Effectiveness Data and Information Set (HEDIS) measures;
6. MCMC plan requirements related to the existing children’s preventive care requirements of the Population Health Management Program;
7. Evidence of progress in reducing racial and ethnic disparities for well-child visits and immunizations for children served by the Medi-Cal program;
8. Evidence of Medi-Cal managed care plan compliance with contractual requirements to train providers on EPSDT requirements, and the number of providers trained; and,
9. Level of accuracy of Medi-Cal managed care plan provider directories, based on the most recent available results of provider directory validation.
10. Requires DHCS to submit a report to the Legislature, and post it on its website, no later than July 1, 2024, with all of the following data:
11. For the 2019, 2020, and 2021, and 2022 calendar years, as one cohort, the number of children zero to five years of age and, as a separate cohort, the number of children six to 18 years of age, who are Medi-Cal beneficiaries receiving any of the following early childhood preventive or developmental services, disaggregated by age-related cohort and by service type: immunizations, blood lead screenings, physical examinations, developmental screenings, nutrition screenings, mental health screenings, dental screenings, vision screenings, hearing screenings, autism spectrum disorder screenings, developmental surveillance, and behavioral, social, or emotional screenings.
12. For the 2019, 2020, and 2021, and 2022 calendar years, the number of pregnant persons, and the number of postpartum persons, who are Medi-Cal beneficiaries receiving maternal depression screenings; tobacco, alcohol, or drug use assessments; or depression or suicide risk screenings. These screenings are to be disaggregated by pregnancy or postpartum status and by service type.
13. Requires information about disparities across racial or ethnic groups, primary languages spoken at home, services areas or counties of the state, and age groups within the cohort for each of the two cohorts of children described in a) above and the pregnant and postpartum persons described in b) above.
14. Requires the reports to be submitted according to existing law on the submission of reports to the Legislature by a state or local agency. Repeals the bill on January 1, 2030.

FISCAL EFFECT:

According to the Assembly Appropriations Committee, costs of an unknown amount, possibly in the mid hundreds of thousands of dollars, for DHCS to determine how the MCMC plans will report information on the geographic distribution of providers, analyze the information, and prepare reports (General Fund, federal funds).

PRIOR VOTES:

COMMENTS:

1. Author’s statement. According to the author, this bill represents an important step toward providing millions of California children as well as pregnant and postpartum individuals with access to critical care that is necessary to prevent life-long and life-threatening illness and disease. Our state’s most vulnerable populations are receiving a fraction of the services they are entitled to as a MCMC plan beneficiary, often as a result of provider shortages leading to significant wait times or far distances that a family would have to travel for an appointment. By working with DHCS and MCMC plans to identify how many providers are necessary to meet time and distance standards, we can get to work on solving these provider shortages and ensuring that everyone has access to high-quality care options.
2. Children’s preventive services in Medi-Cal. Medi-Cal includes a very comprehensive pediatric preventive services mandate stemming from federal EPSDT requirement and the Affordable Care Act preventive care requirement.
3. EPSDT. 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 (CMS). According to CMS, the EPSDT benefit is more robust than the Medicaid benefit for adults and is designed to assure that children receive early detection and care, so that health problems are averted or diagnosed and treated as early as possible. The goal of EPSDT is to assure that individual children get the health care they need when they need it—the right care to the right child at the right time in the right setting. 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. All MCMC plans must provide EPSDT preventive services, including screenings, designed to identify health and developmental issues as early as possible. MCMC plans must provide plan enrollees with appropriate referrals for diagnosis and treatment without delay.
4. The Affordable Care Act 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), an agency of the U.S. Department of Health and Human Services. 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 American Academy of Pediatrics (AAP). The AAP develops theory-based and evidence-based 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 periodicity schedule indicates specific preventive screenings and procedures that are to be provided to children at age-specific periodic intervals from birth through age 21. MCMC plans are required to use the current Bright Futures periodicity schedule and guidelines for enrollees under age 21, including health and developmental screening services, physical examination, dental services, vision services, and hearing services. MCMC plans must provide all age-specific assessments and services required by the MCMC plan contract and the Bright Futures periodicity schedule.
5. 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. The audit included the following key findings:
6. Lack of awareness about available preventive services. The audit found that there was a lack of awareness about the availability of preventive services for families and a lack awareness by MCMC plans that children should be receiving mandatory preventive services. One of the auditor’s recommendations to address this issue was for DHCS to provide to the families of eligible children clearer and more comprehensive information about those services. DHCS released an updated draft of the Evidence of Coverage (EOC) that makes clearer preventive services offered under the EPSDT program in 2019;
7. Access and utilization. The audit found that DHCS requires MCMC plans to report on performance measures for only a portion of the required preventive services. Utilization rates were higher in that portion of services that require reporting. To improve access and utilization rates, the audit recommended that DHCS establish by March 2020 performance measures that cover children’s preventive 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 both the CMS child and adult 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 MCMC plans. DHCS contracts with an external quality review organization 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. DHCS also agreed to increase MCMC plan sanctions, as appropriate, so that it may take quicker punitive action when MCMC plans are found out of compliance; and,
8. Alternative access standards. The auditor’s report found children’s access to preventive care shows notable deficiencies with respect to both the number and location of providers who offer children’s preventive services. CMS’s 2016 Managed Care Final Rule (final rule) required the state to develop and enforce new time and distance standards for access to providers. AB 205 (Wood, Chapter 738, Statutes of 2017) established standards for how long, or how far, beneficiaries should have to travel to have access to primary care providers and specialists. MCMC plans who cannot meet those standards can request and receive approval for an alternative access standard.

According to DHCS, there was a total of 182,000 possible alternative access standard requests that could have been submitted. MCMC plans actually submitted nearly 80,000 requests, although DHCS indicates some of those requests were duplicates. DHCS approved nearly 10,000 of those requests. Fifty-two counties had at least one alternative access request approved in their county. Some of the alternative access standards reflect the difficulty in finding a specialist in a rural area. For instance, some families in Mono County may have to travel almost nine hours, or 365 miles, to see a pediatric dermatologist instead of the 90 minutes and 60 miles permitted under the original access standards. There also remains challenges in access to primary care. In San Bernardino County, some families may have to travel nearly two hours, or 70 miles, to see a pediatric primary care physician instead of the 30 minutes and ten miles permitted under the original access standards. The auditor’s report noted that MCMC plans with more alternative access requests had lower rates of utilization for children’s preventive services.

The implementation of the alternative access standards has led to children in many parts of the state with limited access to care. DHCS’ procedure for reviewing alternative access standards requests includes determining whether the proposed alternative standard is reasonable. The auditor’s report questions whether some of the approved alternative standards were reasonable, and suggests that rather than approving such extreme standards, DHCS could require MCMC plans to provide out-of-network access in such situations.

1. September 2022 follow up report to the 2019 audit. Recently the State Auditor issued a follow up report to the 2019 audit finding that DHCS has been unsuccessful in increasing the percentage of children receiving the preventive services required by Medi‑Cal. From fiscal years 2018–19 through 2020–21, DHCS continued to provide these services to less than half of the children in Medi‑Cal, leaving an average of 2.9 million children per year missing at least some preventive services. The number of children in Medi‑Cal who received preventive care decreased during the COVID-19 pandemic. In fiscal year 2020–21, less than 42% of children received the required number of preventive services, which compared to a pre-pandemic level of almost 48% in fiscal year 2018–19. The percentage of children in Medi‑Cal receiving the required amounts of preventive care continued to be even lower among certain age groups during the most recent three fiscal years. For example, nearly three quarters of two-year-olds in Medi‑Cal did not receive the required number of preventive services, which includes blood lead testing and screening for developmental disorders. The follow up report also found in the more than three years since its initial recommendations were issued, DHCS fully implemented just six of the 14 recommendations. The report specifically called out DHCS’s failure to distribute outreach materials during the pandemic, failure to ensure that provider directories were accurate, and failure to increase the number of providers available.

DHCS responded, agreeing with seven of the remaining eight recommendations that had not been fully implemented, indicating steps they were taking to meet those recommendations. On the eighth recommendation to identify the number of providers needed to ensure adequate access, DHCS denied responsibility, stating that workforce issues were not within their jurisdiction. DHCS also pointed to a number of ongoing initiatives intended to improve children’s access to health care services in Medi-Cal, some of which are still in development.

This bill aims to follow up on the outstanding issues regarding children’s access to providers and preventive services by requesting: 1) a network adequacy analysis of pediatric providers; 2) a report including that analysis and other steps DHCS has taken to oversee MCMC plan requirements regarding children’s preventive services; and, 3) a report on the number of children and pregnant and postpartum women receiving specific preventive services.

1. Prior legislation. AB 1004 (McCarty, Chapter 387, Statutes of 2019) requires that screenings provided as an EPSDT benefit include developmental screenings for individuals zero to three and requires MCMC plans to ensure that providers who contract with these plans provide the screenings according to the Bright Futures Guidelines and Recommendations for Preventive Pediatric Health Care.

AB 1642 (Wood, Chapter 465, Statutes of 2019) among other things, increases the maximum civil penalty amounts in existing law for MCMC plans and expands the bases for DHCS to levy sanctions against MCMC plans. Requires MCMC plans seeking exceptions from appointment travel time standards to include a description of how the plan intends to arrange for beneficiaries to access covered services if the health care provider is located outside of the time and distance standards.

1. Support. Sponsor, The Children’s Partnership writes that this bill would help the state identify where more Medi-Cal providers are needed in order to increase the number of providers in those identified areas. It would bring California one step closer to providing equitable access to quality health care for the approximately 5.5 million children in California who receive medical care through Medi-Cal. Children covered by Medicaid programs are more likely to be born with low birth weights or have developmental delays, learning disorders, or other medical conditions requiring quality health care. The California State Auditor found that DHCS is providing less than half of the children on Medi-Cal with prevention services, which means an average of 2.9 million children are missing some of these essential services. Investments in quality early identification and intervention saves money in the long-term by reducing or eliminating the costs of special education services, repetition, child welfare, and juvenile justice.
2. Policy comments. The author should reconsider the reporting period required in the bill. Currently, the bill is looking at compliance for recommended pediatric and maternal screenings that overlap with the data analyzed in the follow-up audit report. Furthermore, most of this time period is during the public health emergency and prior to the implementation of the CalAIM initiative, which imposed new requirements on MCMC plans. Moving the reporting period back to pick up where the follow-up report leaves off would better demonstrate whether DHCS’s CalAIM initiative and other efforts to improve access to pediatric preventive services, as well as whether DHCS’s new contracts with the MCMC plans have had any effect.

Additionally, the author should consider aligning the network adequacy study requirements with the existing network adequacy study that DHCS is in the process of contracting out to comply with the Terms and Conditions of the CalAIM 1915(b) waiver. There, CMS required that DHCS do a full network adequacy study of the MCMC plans across all lines of business, due no later than 90 days after December 31, 2025. Based on the recently released Request for Information soliciting bids for this study, data on the MCMC plans Medi-Cal networks should be available by May 2024. Such data would presumably be more accurate than data supplied by the MCMC plans and would not require the duplication of resources.

1. Amendments. The committee and the author have agreed on amendments to streamline this bill into one report that would include a pediatric network adequacy study, data from the 2021-2022 – 2023-2024 fiscal years on the number of children and pregnant and postpartum women receiving specified services, along with other steps DHCS has taken to oversee MCMC plan requirements regarding children’s preventive services. This report would be due January 1, 2025.

SUPPORT AND OPPOSITION:

Support: The Children’s Partnership (sponsor)

California Association for Health Services at Home

California Hospital Association

California Optometric Association

California Pan-Ethnic Health Network

Children’s Bureau of Southern California

Depression and Bipolar Support Alliance California
National Health Law Program

The Los Angeles Trust for Children’s Health

Western Center on Law & Poverty

Oppose: None received.

-- END --

ASSEMBLY THIRD READING

ATR Bill Id:AB 1202

Author:(Lackey)

As Amended Ver:March 29, 2023

Majority vote

SUMMARY

Requires Medi-Cal managed care plans to produce an analysis on Medi-Cal providers needed to ensure plan compliance with the time or distance and appointment time standards for pediatric primary care, and requires the Department of Health Care Services (DHCS) to produce a related legislative report on progress in implementing steps to improve utilization of children's preventive services.

Major Provisions

COMMENTS

1. Children's Preventive Health Services in Medi-Cal. Access to pediatric providers for well-child visits is necessary for children to receive recommended preventive services, including screening assessments, vaccinations, developmental surveillance, risk factor reduction interventions, and other services. Medi-Cal covers periodic screening assessments for infants, children, and adolescents under 21 years of age, as specified in the American Academy of Pediatrics (AAP) Bright Futures® preventive healthcare periodicity schedule. The AAP Bright Futures® periodicity schedule provides clear, comprehensive guidance on recommended services at each well-child visit, corresponding to each age milestone up to age 21. For instance, it specifies developmental screening is recommended at well-child visits occurring at nine months, 18 months, and 30 months of age.

Children's preventive health care services are required to be provided by federal law, which establishes an entitlement to the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit. The EPSDT benefit provides a comprehensive array of prevention, diagnostic, and treatment services for individuals under the age of 21 who are enrolled in Medi-Cal. DHCS issued All-Plan Letter 19-010 in 2019 to clarify and provide guidance to Medi-Cal managed care plans on their obligations to provide preventive health services per the AAP Bright Futures® periodicity schedule, under EPSDT.

1. Time, Distance, and Appointment Time Standards. The vast majority of children enrolled in Medi-Cal receive services through a managed care plan. In order to ensure meaningful access to health care with a health plan network, state law establishes allowable time and distance standards between beneficiaries and providers of many health care services, which Medi-Cal managed care plans must meet. The standards require that a beneficiary travel no more than 10 miles or 30 minutes from the beneficiary's residence to reach a provider for primary care, including pediatric primary care. DHCS is authorized to grant exceptions to these standards under circumstances specified in law.
2. Bureau of State Audits (BSA) Audit. 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. BSA 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 manage care plans, but it does not provide effective guidance and oversight;
   6. DHCS does not provide adequate information to plans, providers, and beneficiaries about the services it expects children to receive;
   7. DHCS does not ensure that plans regularly identify and address underutilization of children's preventive services; and,
   8. DHCS has not followed up on plans' efforts to mitigate cultural disparities in the usage of preventive services.

BSA made a number of recommendations to address low rates of children's preventive services, most of which DHCS agreed to implement. However, DHCS declined to implement one recommendation that is the subject of this bill. Specifically, the auditor recommended that DHCS identify where more Medi‑Cal providers are needed and request additional funding from the Legislature to increase the number of providers in those identified areas. DHCS indicated it does not plan to implement that recommendation, citing its belief that broader workforce recruitment is beyond DHCS' purview. DHCS's response is discussed further below.

On April 30, 2019, the Joint Legislative Audit Committee and Assembly Committee on Health held a joint hearing to review the audit report and the DHCS response. On November 4, 2019, the Assembly Committee on Health and Senate Committee on Health held a joint informational hearing to review findings and recommendations related to the audit, as well as the standard Six Month Auditee Implementation Progress Report.

1. Follow-Up Audit Findings. On September 3, 2022, the BSA issued a follow-up audit to the original 2019 audit, titled "Department of Health Care Services Is Still Not Doing Enough to Ensure That Children in Medi‑Cal Receive Preventive Health Services." The BSA found DHCS made progress in implementing the 2019 audit's recommendations, but it has yet to fully implement eight of the 14 recommendations, and many of DHCS's efforts to improve its oversight of health plans' provision of children's preventive services were placed on hold during the COVID-19 pandemic. According to data analyzed by the BSA, from fiscal years 2018–19 through 2020–21, less than half of all children in Medi-Cal received all required preventive services, leaving an average of 2.9 million children per year missing at least some preventive services. BSA found in fiscal year 2020–21, less than 42% of children received the required number of preventive services, which compares unfavorably to a pre-pandemic level of almost 48% in fiscal year 2018–19.

The audit noted concerns related to DHCS doing limited outreach and not distributing outreach materials during the COVID-19 pandemic as well as continued concerns about the accuracy of provider directories. The audit also notes DHCS approved nearly 10,500 exceptions related to managed care time and distance standards for pediatric services in fiscal year 2020–21, according to an external reviewer. For example, the audit states, DHCS approved an exception for part of Monterey County that allowed a plan to require beneficiaries to travel up to 58 miles, or more than three hours, to reach a pediatric primary care physician.

1. DHCS Response to the September 2022 Audit; Current Efforts. As noted, DHCS fully implemented six of the audit recommendations and seven more recommendations are partially implemented. For instance, BSA recommended DHCS provide clearer and more comprehensive information about children's preventive services in its written materials. In February 2023, DHCS released a consumer-tested outreach toolkit that includes brochures specific to Medi-Cal services for children and teens under EPSDT that will be shared annually with beneficiaries, as well as a "Know Your Rights Guide" detailing what actions beneficiaries can take if they are denied services.

In its response, the department cites a number of ongoing initiatives to improve children's health care in Medi-Cal. Some of the initiatives have been implemented and others are in development. DHCS notes the March 2022 Medi-Cal's "Strategy to Support Health and Opportunity for Children and Families" is a forward-looking policy agenda for children and families enrolled in Medi-Cal, intended to unify the common threads of existing and newly proposed child and family health initiatives, and solidify DHCS' accountability and oversight of children's services. A number of the strategies are supportive of ensuring continued focus on children's health and increasing utilization of children's preventive services.

In its response to the 2022 BSA audit recommendation that DHCS should identify the number of providers needed to ensure access, DHCS again indicated it does not have jurisdiction to address workforce issues and does not plan to implement the recommendation. However, DHCS indicates it plans to have an external evaluator conduct an access assessment by reviewing the various components of access, comparing managed care plan networks and access to care with commercial and Medicare Advantage markets. Through the assessment, DHCS aims to compare access in Medi-Cal managed care to access for Californians who receive health coverage through the commercial or Medicare Advantage markets. DHCS explains this will allow it to assess if any barriers to access are a reflection of systematic problems across the entire health care system—such as issues related to workforce pipeline – or if access barriers are specific to Medi-Cal. In addition, the assessment will track different levels of access to help determine whether issues exist at the managed care level (network adequacy), provider level (scheduling practices, responsiveness to member scheduling requests, etc.) or both. DHCS indicates the results of the assessment will be shared with the Centers for Medicare & Medicaid Services in March 2026.

The reporting required by this bill is not in conflict with the planned analysis, but will provide an assessment of the number and location of providers needed, which is intended to help the Legislature target workforce investments specifically to improve access to children's health care.

According to the Author

In response to a follow-up audit by BSA examining low rates of children's preventive health care utilization in Medi-Cal, this bill is intended to require DHCS to provide actionable information about how many pediatric providers are needed in order for Medi-Cal managed care plans to comply with network adequacy and access standards for pediatric care, for children enrolled in Medi-Cal. The author indicates this information would be useful to allow the Legislature to target resources to augment the pediatric health care workforce in areas of needed.

Arguments in Support

The Children's Partnership and health providers support this bill. Supporters argue this bill will help the state identify where more Medi-Cal providers are needed and request additional funding from the Legislature to increase the number of providers in those identified areas, as recommended by the BSA. California Chapter of the American College of Emergency Physicians writes that they would support this bill if amended to include emergency care in the assessment, given emergency services also play an important role in care the delivery of pediatric care, especially for the most vulnerable populations.

Arguments in Opposition

There is no known opposition.

FISCAL COMMENTS

According to the Assembly Appropriations Committee, costs of an unknown amount, possibly in the mid hundreds of thousands of dollars, for DHCS to determine how the Medi-Cal managed care plans will report information on the geographic distribution of providers, analyze the information, and prepare reports (General Fund, federal funds).

VOTES

ASM HEALTH: 14-0-1

YES: Wood, Waldron, Aguiar-Curry, Arambula, Boerner Horvath, Flora, Vince Fong, Maienschein, McCarty, Joe Patterson, Rodriguez, Santiago, Villapudua, Weber

ABS, ABST OR NV: Wendy Carrillo

ASM APPROPRIATIONS: 15-0-1

YES: Holden, Megan Dahle, Bryan, Calderon, Wendy Carrillo, Dixon, Mike Fong, Hart, Lowenthal, Mathis, Papan, Pellerin, Sanchez, Weber, Ortega

ABS, ABST OR NV: Robert Rivas

UPDATED

VERSION: March 29, 2023

CONSULTANT: Lisa Murawski / HEALTH / (916) 319-2097 FN: 0000792

Date of Hearing: May 3, 2023

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Chris Holden, Chair

ABPCA Bill Id:AB 1202

Author:(Lackey) – As Amended Ver:March 29, 2023

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

SUMMARY:

This bill requires each Medi-Cal managed care plan (MCMC plan) to analyze the geographic distribution of Medi-Cal providers needed to ensure compliance with time or distance and appointment time standards for pediatric primary care, and report the results of the analysis to the Department of Health Care Services (DHCS). This bill requires DHCS to produce a legislative report that includes a summary of the information provided by the MCMC plans, evidence of progress and compliance with time and distance standards, and suggestions for holding MCMC plans accountable.

This bill also requires DHCS to prepare a report about disparities among pediatric Medi-Cal beneficiaries and pregnant and postpartum Medi-Cal beneficiaries, as specified, and to submit it to the Legislature and make it publicly available.

FISCAL EFFECT:

Costs of an unknown amount, possibly in the mid hundreds of thousands of dollars, for DHCS to determine how the MCMC plans will report information on the geographic distribution of providers, analyze the information, and prepare reports (General Fund, federal funds).

COMMENTS:

1. Purpose. This bill is sponsored by the Children’s Partnership. According to the author:

In response to a follow-up audit by the Bureau of State Audits (BSA) examining low rates of children’s preventive health care utilization in Medi-Cal, this bill is intended to require DHCS to provide actionable information about how many pediatric providers are needed in order for MCMC plans to comply with network adequacy and access standards for pediatric care for Medi-Cal child enrollees…This information will be useful to allow the Legislature to target resources to augment the pediatric health care workforce in areas of needed.

1. Background.
   
   Time, Distance, and Appointment Time Standards. The vast majority of children enrolled in Medi-Cal receive services through a managed care plan. To ensure meaningful access to health care with a health plan network, state law establishes allowable time and distance standards for beneficiaries and providers of many health care services, which Medi-Cal managed care plans must meet. The standards require that a beneficiary travel no more than 10 miles or 30 minutes from the beneficiary's residence to reach a provider for primary care, including pediatric primary care. DHCS is authorized to grant exceptions to these standards under specified circumstances.
   
   Bureau of State Audits (BSA) Reports. In March 2019, BSA released “Department of Health Care Services - Millions of Children in Medi-Cal Are Not Receiving Preventive Health Services.” BSA found millions of children enrolled in Medi-Cal do not receive all required preventive services; many do not have adequate access to Medi-Cal pediatric providers; limited provider access is due, in part, to low Medi-Cal reimbursement rates; and states with higher utilization rates offer financial incentive programs that California could implement. BSA made a number of recommendations to address low rates of children’s preventive services, most of which DHCS agreed to implement.
   
   In 2022, the BSA issued a follow-up to the original 2019 audit, reporting DHCS had yet to fully implement eight of the 14 recommendations, and many of DHCS's efforts to improve its oversight of health plans' provision of children's preventive services were placed on hold during the COVID-19 pandemic. In FY 2020–21, less than 42% of children received the required number of preventive services, lower than a pre-pandemic level of almost 48% in FY 2018–19.
   
   DHCS maintains it does not have jurisdiction to address workforce issues and does not plan to implement the recommendation. However, DHCS indicates it plans to have an external evaluator conduct an access assessment comparing access to care in managed care plan networks vs. commercial and Medicare Advantage markets. DHCS explains this will allow it to assess whether barriers to access are a reflection of systematic problems across the entire health care system, such as issues related to workforce pipeline, or if access barriers are specific to Medi-Cal.
   
   The reports required by this bill but will provide an assessment of the number and location of providers needed, which is intended to help the Legislature target workforce investments to improve access to children’s health care.
2. Prior Legislation. AB 1642 (Wood), Chapter 465, Statutes of 2019, increased DHCS’s authority to levy sanctions against Medi-Cal managed care plans, and broadened its authority to find noncompliance beyond medical audits, increased maximum civil penalty amounts, and required penalty revenue to be deposited into the General Fund for use, upon appropriation by the Legislature, to address workforce problems and improve access to care in the Medi-Cal program. AB 1642 also placed additional requirements on plans seeking exceptions from time and distance standards and required a plan to assist enrollees with long travel times to obtain a closer appointment or arrange for nonmedical transportation.

Analysis Prepared by: Allegra Kim / APPR. / (916) 319-2081

Date of Hearing: March 21, 2023

ASSEMBLY COMMITTEE ON HEALTH

Jim Wood, Chair

ABPCA Bill Id:AB 1202

Author:(Lackey) – As Introduced Ver:February 16, 2023

SUBJECT: Medi-Cal: time or distance standards: children’s health care services.

SUMMARY: Requires the Department of Health Care Services (DHCS) to produce a legislative report on the number of providers needed to provide Medi-Cal eligible children access to health care services throughout the state. Specifically, this bill:

1. Requires DHCS to conduct an analysis to identify the number of Medi-Cal providers needed to ensure adequate access to children’s health care services, through compliance by Medi-Cal managed care plans with time and distance standards, across all service areas or counties of the state.
2. Requires DHCS to submit the report to the Legislature no later than January 1, 2026.

EXISTING LAW:

1. Requires a Medi-Cal managed care plan to maintain a network of providers that are located within specified time and distance standards for specified services. [Welfare and Institutions Code (WIC) §14197 (b)]
2. Establishes time or distance standards for primary care, both adult and pediatric, as 10 miles or 30 minutes from the beneficiary’s place of residence. [WIC §14197(b)(1)]
3. Allows DHCS, upon request of a Medi-Cal managed care plan, to authorize alternative access standards for the established time or distance standards if either of the following occur:
   1. The requesting Medi-Cal managed care plan has exhausted all other reasonable options to obtain providers to meet the applicable standard; or,
   2. DHCS determines that the requesting Medi-Cal managed care plan has demonstrated that its delivery structure is capable of delivering the appropriate level of care and access. [WIC §14197(f)(2)]
4. Allows, if a Medi-Cal managed care plan cannot meet the time and distance standards set forth in statute, the plan to submit to DHCS a request for alternative access standards, in the form and manner specified by DHCS. [WIC §14197(f)(3)]
5. Establishes early and periodic screening, diagnosis, and treatment (EPSDT) as a Medi-Cal benefit for any individual under 21 years of age is covered, consistent with the requirements of federal law, as specified. [WIC §14132(v)]
   
6. Establishes, within the Department of Health Access and Information, numerous health care workforce programs intended to improve access to health care in medically underserved areas with a shortage of health professionals. [Health and Safety Code § 127825 et seq.]

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

COMMENTS:

1. PURPOSE OF THIS BILL. This bill is sponsored by the Children’s Partnership as a step to improve access to pediatric providers for children enrolled in Medi-Cal. According to the author, in response to a follow-up audit by the Bureau of State Audits (BSA) examining low rates of children’s preventive health care utilization in Medi-Cal, this bill is intended to require DHCS to provide actionable information about how many pediatric providers are needed in order for Medi-Cal managed care plans to comply with network adequacy and access standards for pediatric care, for children enrolled in Medi-Cal. The author indicates this information would be useful to allow the Legislature to target resources to augment the pediatric health care workforce in areas of needed.
2. BACKGROUND.
   1. Children’s Preventive Health Services in Medi-Cal. Access to pediatric providers for well-child visits is necessary for children to receive recommended preventive services, including screening assessments, vaccinations, developmental surveillance, risk factor reduction interventions, and other services. Medi-Cal covers periodic screening assessments for infants, children, and adolescents under 21 years of age, as specified in the American Academy of Pediatrics (AAP) Bright Futures® preventive healthcare periodicity schedule. The AAP Bright Futures® periodicity schedule provides clear, comprehensive guidance on recommended services at each well-child visit, corresponding to each age milestone up to age 21. For instance, it specifies developmental screening is recommended at well-child visits occurring at nine months, 18 months, and 30 months of age.
      
      Children’s preventive health care services are required to be provided by federal law, which establishes an entitlement to the EPSDT benefit. The EPSDT benefit provides a comprehensive array of prevention, diagnostic, and treatment services for individuals under the age of 21 who are enrolled in Medi-Cal. DHCS issued All-Plan Letter (APL) 19-010 in 2019 to clarify and provide guidance to Medi-Cal managed care plans on their obligations to provide preventive health services per the AAP Bright Futures® periodicity schedule, under EPSDT.
      
   2. Time, Distance, and Appointment Time Standards. The vast majority of children enrolled in Medi-Cal receive services through a managed care plan. In order to ensure meaningful access to health care with a health plan network, state law establishes allowable time and distance standards between beneficiaries and providers of many health care services, which Medi-Cal managed care plans must meet. The standards require that a beneficiary travel no more than 10 miles or 30 minutes from the beneficiary's residence to reach a provider for primary care, including pediatric primary care. DHCS is authorized to grant exceptions to these standards under circumstances specified in law (see 3) of Existing Law, above).
      
   3. BSA Audit. 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. BSA 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 manage care plans, but it does not provide effective guidance and oversight;
      6. DHCS does not provide adequate information to plans, providers, and beneficiaries about the services it expects children to receive;
      7. DHCS does not ensure that plans regularly identify and address underutilization of children's preventive services; and,
      8. DHCS has not followed up on plans' efforts to mitigate cultural disparities in the usage of preventive services.

BSA made a number of recommendations to address low rates of children’s preventive services, most of which DHCS agreed to implement. However, DHCS declined to implement one recommendation that is the subject of this bill. Specifically, the auditor recommended that DHCS identify where more Medi‑Cal providers are needed and request additional funding from the Legislature to increase the number of providers in those identified areas. DHCS indicated it does not plan to implement that recommendation, citing its belief that broader workforce recruitment is beyond DHCS' purview. DHCS’s response is discussed further below.

On April 30, 2019, the Joint Legislative Audit Committee and Assembly Committee on Health held a joint hearing to review the audit report and the DHCS response. On November 4, 2019, the Assembly Committee on Health and Senate Committee on Health held a joint informational hearing to review findings and recommendations related to the audit, as well as the standard Six Month Auditee Implementation Progress Report.

• 1. Follow-Up Audit Findings. On September 3, 2022, the BSA issued a follow-up audit to the original 2019 audit, titled “Department of Health Care Services Is Still Not Doing Enough to Ensure That Children in Medi‑Cal Receive Preventive Health Services.” The BSA found DHCS made progress in implementing the 2019 audit's recommendations, but it has yet to fully implement eight of the 14 recommendations, and many of DHCS's efforts to improve its oversight of health plans' provision of children's preventive services were placed on hold during the COVID-19 pandemic. According to data analyzed by the BSA, from fiscal years 2018–19 through 2020–21, less than half of all children in Medi-Cal received all required preventive services, leaving an average of 2.9 million children per year missing at least some preventive services. BSA found in fiscal year 2020–21, less than 42% of children received the required number of preventive services, which compares unfavorably to a pre-pandemic level of almost 48% in fiscal year 2018–19.
     
     The audit noted concerns related to DHCS doing limited outreach and not distributing outreach materials during the COVID-19 pandemic as well as continued concerns about the accuracy of provider directories. The audit also notes DHCS approved nearly 10,500 exceptions related to managed care time and distance standards for pediatric services in fiscal year 2020–21, according to an external reviewer. For example, the audit states, DHCS approved an exception for part of Monterey County that allowed a plan to require beneficiaries to travel up to 58 miles, or more than three hours, to reach a pediatric primary care physician.
     
  2. DHCS Response to the September 2022 Audit; Current Efforts. As noted, DHCS fully implemented six of the audit recommendations and seven more recommendations are partially implemented. For instance, BSA recommended DHCS provide clearer and more comprehensive information about children’s preventive services in its written materials. In February 2023, DHCS released a consumer-tested outreach toolkit that includes brochures specific to Medi-Cal services for children and teens under EPSDT that will be shared annually with beneficiaries, as well as a “Know Your Rights Guide” detailing what actions beneficiaries can take if they are denied services.
     
     In its response, the department cites a number of ongoing initiatives to improve children’s health care in Medi-Cal. Some of the initiatives have been implemented and others are in development. DHCS notes the March 2022 Medi-Cal's “Strategy to Support Health and Opportunity for Children and Families” is a forward-looking policy agenda for children and families enrolled in Medi-Cal, intended to unify the common threads of existing and newly proposed child and family health initiatives, and solidify DHCS’ accountability and oversight of children’s services. A number of these strategies are supportive of ensuring continued focus on children’s health and increasing utilization of children’s preventive services. They include, for instance:
     1. A new leadership structure at DHCS, including identifying a “child health champion;”
     2. Implementing a new population health management strategy to ensure plans identify and serve children in need of care coordination;
     3. Conducting an education and outreach campaign regarding EPSDT for enrollees, providers, and managed care plans to support families (mentioned above);
     4. Increasing pediatric and maternity care performance standards for managed care plans;
     5. Support school partnerships by requiring plans to provide Medi-Cal services, including preventive services and adolescent health services, provided in schools or by school-affiliated health providers;
     6. Streamline DHCS pediatric dashboards to enhance transparency and increase usability;
     7. Enhance and sustain payments to pediatric providers to increase use of key preventive and screening services for children and families;
     8. Implement expanded postpartum eligibility for 12 months and new maternal and child-focused benefits, including dyadic, community health worker, and doula services, and clarify family therapy coverage;
     9. Launch Enhanced Care Management for children; and
     10. Implement the Children and Youth Behavioral Health Initiative, including a State-defined all-payers fee schedule for behavioral health services provided at schools and other efforts.

In its response to the 2022 BSA audit recommendation that DHCS should identify the number of providers needed to ensure access, DHCS again indicated it does not have jurisdiction to address workforce issues and does not plan to implement the recommendation. However, DHCS indicates it plans to have an external evaluator conduct an access assessment by reviewing the various components of access, comparing managed care plan networks and access to care with commercial and Medicare Advantage markets. Through the assessment, DHCS aims to compare access in Medi-Cal managed care to access for Californians who receive health coverage through the commercial or Medicare Advantage markets. DHCS explains this will allow it to assess if any barriers to access are a reflection of systematic problems across the entire health care system—such as issues related to workforce pipeline—or if access barriers are specific to Medi-Cal. In addition, the assessment will track different levels of access to help determine whether issues exist at the managed care level (network adequacy), provider level (scheduling practices, responsiveness to member scheduling requests, etc.) or both. DHCS indicates the results of the assessment will be shared with the Centers for Medicare & Medicaid Services in March 2026.

The reporting required by this bill is not in conflict with the planned analysis, but will provide an assessment of the number and location of providers needed, which is intended to help the Legislature target workforce investments specifically to improve access to children’s health care.

1. SUPPORT. Supporters argue this bill will help the state identify where more Medi-Cal providers are needed and request additional funding from the Legislature to increase the number of providers in those identified areas, as recommended by the BSA.
   
2. PREVIOUS LEGISLATION. AB 1642 (Wood), Chapter 465, Statutes of 2019, increased DHCS’s authority to levy sanctions against Medi-Cal managed care plans, and broadened DHCS authority to find noncompliance beyond medical audits and penalty revenue to be deposited into the General Fund for use, and upon appropriation by the Legislature, to address workforce issues in the Medi-Cal program and to improve access to care in the Medi-Cal program. AB 1642 also placed additional requirements on plans seeking exceptions from time and distance standards and requires a plan to assist enrollees with long travel times to obtain a closer appointment or to arrange for nonmedical transportation.
3. AMENDMENTS. In consultation with the Committee, the author has proposed amendments to strengthen and clarify this bill, described below:
   1. Instead of requiring DHCS to report this information, require Medi-Cal managed care plans must report to DHCS the number and geographic distribution of providers needed to comply with time and distance and appointment time standards, and require DHCS to summarize and report the results.
   2. Require DHCS to report to the Legislature on actions DHCS indicated it would take in response to additional recommendations in the BSA audit, including actions related to holding plans accountable for improved children’s preventive services utilization, reducing disparities, implementing Population Health Management requirements, implementing provider training on Medi-Cal coverage requirements for children, and improving accuracy of provider directories.
   3. Require DHCS to issue a data report, disaggregated by age, geography, and demographic information, as specified, which includes a number of children’s and health preventive services and maternal services relevant to children’s health, such as maternal depression screening.

(a) No later than January 1, 2025, each Medi-Cal managed care plan The department shall conduct, and report to the department the results of, an analysis to identify the number and, as appropriate, the geographic distribution of Medi-Cal providers needed to ensure adequate access to children’s health care services, through compliance by a Medi-Cal managed care plan’s compliance with the time or distance and appointment time standards described in Section 14197 for pediatric primary care, across all service areas or counties of the state of the plan.

(b) (1) No later than January 1, 2026, the department shall prepare a report of the analysis described in subdivision (a) and (b) and shall submit the a report to the Legislature no later than January 1, 2026.that includes the following:

(i) A summary of the results reported by plans, as described in subdivision (a).

(ii) Specific steps the department has taken to hold Medi-Cal managed care plans accountable for improving utilization of children’s preventive services, including, but not limited to, the following:

(A) Monitoring the efficacy of managed care plan activities through Healthcare Effectiveness Data and Information Set (HEDIS) measures.

(B) Managed care plan requirements related to the Population Health Management program as specific to children’s preventive care.

(iii) Evidence of progress in reducing racial and ethnic disparities for well-child visits and immunizations for children served by Medi-Cal.

(iv) Evidence of managed care plan compliance with contractual requirements to train providers on EPSDT requirements, and the number of providers trained.

(v) Level of accuracy of Medi-Cal managed care plan provider directories, based on the most recent available results of provider directory validation.

(2) For purposes of the analysis described in subdivision (a), No later than July 1, 2024, the department shall determine publicly issue a report with all of the following data:

(1) For the 2019, 2020, and 2021, and 2022 calendar years, as one cohort, the number of children zero to five years of age, inclusive, and, as a separate cohort, the number of children 6 to 18 years of age, inclusive, who are Medi-Cal beneficiaries receiving any of the following early childhood preventive or developmental services, disaggregated by age-related cohort and by service type:

(A) Immunizations.

(B) Blood lead screenings.

(C) Physical examinations.

(D) Developmental screenings.

(E) Nutrition screenings.

(F) Mental health screenings.

(G) Dental screenings.

(H) Vision screenings.

(I) Hearing screenings.

(J) Autism spectrum disorder screenings.

(K) Developmental surveillance.

(L) Behavioral, social, or emotional screenings.

(2) For each of the two cohorts of children described in paragraph (1), information about any disparities across the following:

(A) Racial or ethnic groups.

(B) Primary languages spoken at home.

(C) Service areas or counties of the state.

(D) Age groups within the cohort.

(3) For the 2019, 2020, and 2021, and 2022 calendar years, the number of pregnant persons, and the number of postpartum persons, who are Medi-Cal beneficiaries receiving any of the following services, disaggregated by pregnancy or postpartum status and by service type:

(A) Maternal depression screenings.

(B) Tobacco, alcohol, or drug use assessments.

(C) Depression or suicide risk screenings.

(4) For the pregnant persons, and for the postpartum persons, described in paragraph (3), information about any disparities across the following:

(A) Racial or ethnic groups.

(B) Primary languages spoken at home.

(C) Service areas or counties of the state.

(D) Age groups.

(3) The report described in paragraph (1) and paragraph (2) shall be submitted in accordance with Section 9795 of the Government Code.

(c) Pursuant to Section 10231.5 of the Government Code, this section shall remain in effect only until January 1, 2030, and as of that date is repealed.

REGISTERED SUPPORT / OPPOSITION:

Support

The Children's Partnership (sponsor)

California Association for Health Services At Home

Opposition

None on file.

Analysis Prepared by: Lisa Murawski / HEALTH / (916) 319-2097