CALIFORNIA HOLDS MEDI-CAL PLANS ACCOUNTABLE FOR ENSURING MEMBERS HAVE ACCESS TO HIGH QUALITY, EQUITABLE CARE
SACRAMENTO — The Department of Health Care Services (DHCS) today published
quality ratings for Medi-Cal managed care plans (MCP) and county behavioral health plans (BHP). DHCS oversees all MCPs to ensure the plans provide members with the best possible care and to increase transparency.
Monetary sanctions are being imposed on MCPs that did not meet or exceed the established minimum performance levels (MPL), meaning the plans failed to provide members with a level of care that reached the quality standards established by DHCS. Today's actions are the result of the MCP contract, effective January 1, 2024, which significantly strengthened quality and health equity requirements for MCPs.
"California is committed to advancing health care quality by holding plan partners accountable to established benchmarks and driving measurable improvements," said
DHCS Director Michelle Baass. "By reinforcing accountability, promoting health equity, fostering collaboration, and partnering with plans, we are enhancing care and improving health outcomes for all Medi-Cal members. Through these joint efforts, DHCS aims to support Medi-Cal managed care plans, county behavioral health plans, and providers in delivering better health outcomes for all Medi-Cal members."
WHY THIS IS IMPORTANT: The quality ratings are part of DHCS' Bold Goals
50x2025 initiative, which targets improvements in children's health, reproductive care, cancer prevention, maternal health, and behavioral health integration. By releasing these ratings, DHCS encourages MCPs and BHPs to provide improved care, particularly in areas like preventive and primary care services as well as behavioral health services.
WHAT THIS MEANS FOR CALIFORNIANS: Based on the quality ratings, MCPs will take corrective actions, including providing more proactive care to members, such as supporting them in finding a primary care provider and scheduling well-child visits, helping with transportation needs to appointments and picking up prescriptions, assisting them with accessing programs like
CalFresh, and screening for eligibility for
Enhanced Care Management and
Community Supports. MCPs will also ensure their network providers increase evening and weekend appointments and reduce wait times to improve access to care. Additionally, BHPs will focus on improving access to timely and culturally responsive behavioral health services. This includes reaching out to members to connect them with therapy and counseling and supporting them in managing serious mental health conditions and substance use disorders (SUD).
NEW SANCTIONS: Of the 24 MCPs contracted with DHCS, 20 (83.3 percent) will be sanctioned for not meeting contractually required MPLs on the Managed Care Accountability Set (MCAS) quality measures, more than in
Measurement Year (MY) 2022. The sanctions range from $25,000 to $819,000, totaling $3,069,000, which is less than MY22.
The MCAS sanctions were determined based on such factors as the number of people affected, changes in the MCP's performance, and the MCP's Healthy Places Index score. The main reasons for this year's sanctions were related to Topical Fluoride for Children (TFL-CH), Child and Adolescent Well-Care Visits, and Cervical Cancer Screening, which together account for about 82 percent of the total sanctions due to their impact on a large population. More than 1.5 million members did not receive TFL-CH services, leading to about $1.1 million of the total sanctions. MCPs will be expected to engage in improvement efforts, such as member and community engagement, and improving health information sharing across delivery systems (e.g., medical, dental, and behavioral health) to improve member access and delivery of all needed health services.
In addition to quality ratings for MCPs, DHCS released the Behavioral Health Accountability Set (BHAS) quality scores for BHPs for the second year. For county BHPs, 71 percent of counties met or exceeded benchmarks for at least half of the mental health measures. County performance was similar for SUD measures, with 80 percent of counties meeting or exceeding benchmarks for at least half of the SUD measures. While no monetary sanctions were issued for BHPs this year, enforcement will begin in future years. DHCS is committed to creating a transparent system with reliable data and building long-term accountability for better behavioral health care.
For a more detailed review of the performance measures, please see the following:
QUALITY IMPROVEMENTS: DHCS is dedicated to supporting MCPs in improving their performance by setting clear targets, providing timely data, and partnering with communities to enhance access to preventive services. DHCS shares best practices, offers technical assistance, and creates regional collaboratives where MCPs can discuss challenges and potential solutions. In 2024, DHCS launched two new statewide collaboratives focusing on children's preventive services and behavioral health integration.
Additionally, DHCS has engaged with BHPs on quality improvement through regular Behavioral Health Regional Collaborative meetings to share best practices and quality improvement strategies. Further, DHCS has partnered with the Institute for Healthcare Improvement (IHI) on a Behavioral Health Demonstration Collaborative designed to enable whole-person care that seamlessly addresses the behavioral, physical, and health-related social needs of Medi-Cal members. Read the
Quality Fact Sheet to learn more about how DHCS is working to improve quality of care for members.
ADDITIONAL INFORMATION: DHCS'
Comprehensive Quality Strategy focuses on improving health outcomes through the Bold Goals 50X2025 initiative. Since 2022, DHCS has been publicly releasing annual
quality measure ratings for all MCPs and requiring quality improvement actions. Since 2023, DHCS has publicly released annual quality measure ratings for all BHPs and will begin requiring quality improvement actions. These efforts, as well as targeted audits of MCPs and BHPs and enhanced quality improvement and oversight, are aimed at improving health outcomes for millions of Californians.
Assembly Bill 1642 (Chapter 465, Statutes of 2019) authorized DHCS to increase sanctions for MCPs that do not meet or exceed required MPLs. The MCP contracts, which became effective on January 1, 2024, promotes a more person-centered, equity-focused, and data-driven Medi-Cal program.
Additionally, in the behavioral health field, the Drug Medi-Cal Organized Delivery System Interagency Agreements and mental health plan contracts require BHPs to establish Quality Improvement Systems and to collect and submit performance measurement data required by DHCS, according to the Comprehensive Quality Strategy. DHCS also released
Behavioral Health Information Notice 24-004 in December 2023 to clarify DHCS requirements for the BHPs' Quality Improvement Systems. DHCS will launch the Behavioral Health Quality Improvement and Health Equity Framework in 2025, which will focus on improving BHAS measure performances.