State Legislature reviews report showing that millions of children in Medi-Cal are not receiving preventive health services

At a recent Senate Health Committee hearing, findings were presented from an audit report which concluded that millions of children do not receive preventative services to which they are entitled under Medi-Cal. 

Due to a variety of problems stipulated by the report, an annual average of 2.4 million children who were enrolled in Medi-Cal over the past five years have not received all of the preventive health services they were promised. 

The Department of Health Care Services (DHCS) is the state agency tasked with overseeing Medi-Cal. Nearly half of California’s children receive health care services through Medi-Cal.

 

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Preventive services consist of routine forms of health care like screenings, check-ups, and patient counseling. According to the Centers for Disease Control and Prevention, providing children with annual preventive health services saves thousands of lives and reduces future health care costs by thousands of dollars per child.

While the positive effects of preventive care are clear, the children’s utilization rate of these services in California is ranked 40th in the country — almost 10 percent below the national average. The utilization rate in California has not improved since fiscal year 2013-2014.  

On the cause of the low utilization rate, the report cites a lack of access to Medi-Cal providers who can deliver necessary pediatric preventive services. Limited access can be traced, in part, to low Medi-Cal reimbursement rates. Services provided through managed care plans to nearly 90 percent of children in Medi-Cal are funded by a monthly premium covered by DHCS.   

The language in the report calls for DHCS to improve its oversight of preventive service delivery to children in Medi-Cal. 

Although it is clear that DHCS cannot control all of the factors that influence whether families use preventive services for their children, it is equally clear from our review that DHCS can carry out its oversight responsibilities more effectively and more proactively. 

To ensure that Medi-Cal beneficiaries have access to providers capable of delivering the services they are eligible for, the State is required by the U.S. Centers for Medicare and Medicaid services to enforce standards that specify a maximum time and distance beneficiaries should have to travel for care. 

But when California began implementing these enforcement standards, plans began submitting requests to DCHS for exemptions in numbers far beyond what the agency had anticipated. The influx of exemption requests “highlighted the fact that there are many parts of California where Medi‑Cal beneficiaries do not have adequate access to the providers they need.”

In addition to the large volume of exemptions, the access standards DHCS allowed were sometimes untenable. The report recounted an instance in San Joaquin County when a DHCS-approved exemption required some families to travel more than 250 miles to see an in-plan pediatric eye specialist instead of the 30 miles permitted under the State’s time and distance standards.

In this and other extreme instances, DHCS could have exercised its option of requiring the plans to allow families to visit a closer out-of-plan provider. However, it did not do so partly because its criteria for evaluating whether alternatives are reasonable focuses primarily on the efforts of the plans to meet the State’s standards and not on whether the resulting times and distances are reasonable for a Medi‑Cal beneficiary to travel.

The report provides several recommendations to the Legislature for improving children’s access to preventive health services, as well as DCHS’s oversight mechanisms. 

    1. Direct DHCS to modify its criteria for evaluating plans’ alternative access standards requests to determine whether the resulting times and distances are reasonable to expect a Medi‑Cal beneficiary to travel.

    2. Require any plans unable to meet those criteria to allow affected members to obtain health services outside of the plan’s network.

    3. Direct DHCS to require such plans to inform affected members that they may obtain those services outside of the plan’s network.

    4. Require plans to assist members in locating a suitable out‑of‑network provider.

The report also recommends that DCHS propose funding increases to the Legislature to recruit providers in areas of need. Increased funding would also make it possible for DCHS to monitor and identify effective incentive programs for plans.