The Supplemental Report of the 2020‑21 Budget Act directs our office to assess a dashboard developed by the Department of Health Care Services (DHCS) to identify and prioritize issues related to Medi‑Cal eligibility functionality in the California Healthcare Eligibility, Enrollment, and Retention System (CalHEERS). This post represents our assessment based on our review of the dashboard and other information gathered from the administration and stakeholders. We then provide opportunities for legislative oversight of the dashboard and associated processes.
CalHEERS Supports Eligibility and Enrollment for Health Benefits Through Covered California and Medi‑Cal. CalHEERS is an information technology (IT) system, jointly administered by Covered California and DHCS, that allows for real‑time eligibility determinations for Medi‑Cal—the state’s Medicaid program—and subsidized health care coverage through Covered California. CalHEERS refers individuals determined by the system to be likely eligible for Medi‑Cal to county eligibility workers for final eligibility determination. County staff then use both CalHEERS and the Statewide Automated Welfare System (SAWS) to determine final program eligibility. (SAWS is made up of multiple IT systems which support such functions as eligibility and benefit determination, enrollment, and case maintenance at the county level for some of the state’s major health and human services programs.)
Development of CalHEERS Continues After Initial Implementation. Implemented beginning in late 2013, CalHEERS continues to be developed to adapt to changes in Medi‑Cal and Covered California eligibility rules, fix existing system defects, and add new functionalities. (System defects are technical problems with an IT system, whereas new functionalities enhance the capabilities of an IT system.) Additional functionalities and defect fixes are identified and prioritized by Covered California, DHCS, and the California Health and Human Services Agency’s Office of Systems Integration, in consultation with other stakeholders including the County Welfare Directors Association (CWDA) and the Service Employees International Union (SEIU). (SEIU represents a large number of county eligibility workers in, among other activities, collective bargaining.) The administration organizes each of the functionalities and fixes that are ready for deployment into one of several CalHEERS releases during the course of the year. (A release is a CalHEERS update that implements several defect fixes and new functionalities at once.) Releases are planned sequentially over a 24‑month period by the administration, with input from stakeholders. This 24‑month “roadmap” of releases guides the continued development and operation of CalHEERS.
Stakeholders Raised Concerns With Identification/Prioritization of Medi‑Cal Eligibility Functionalities in CalHEERS. During the 2020‑21 budget process, CWDA and SEIU notified the Legislature of, among other concerns, ongoing issues with the development of Medi‑Cal eligibility functionalities in CalHEERS. CWDA and SEIU identified several defects in the system, such as the delayed transfer of individuals between Medi‑Cal and subsidized health coverage through Covered California when their income changes (which leads, in some cases, to coverage delays and avoidable premium charges), and the inflexible assignment of individuals to one county even when an individual moves and their case is being processed in another county. CWDA and SEIU also highlighted needed functionalities that were first identified when the state began implementation of CalHEERS in 2013 but have not yet been added, such as the ability for county staff to correct eligibility transactions between CalHEERS and SAWS.
In Response, DHCS Created New Dashboard to Track CalHEERS Issues. In response to CWDA and SEIU’s concerns, DHCS began to develop a “dashboard” that would help catalog each defect and new functionality related to Medi‑Cal eligibility identified by stakeholders in CalHEERS. The administration and stakeholders then would use the dashboard to prioritize each fix and functionality and set time lines for their inclusion in future CalHEERS releases.
Legislature Adopted Supplemental Report Language in 2020‑21. The Legislature adopted supplemental report language in 2020‑21 directing our office to review DHCS’s dashboard and gather information from the administration and stakeholders to provide an assessment of the dashboard and associated processes during the 2021‑22 budget process. More specifically, the Legislature tasked our office with assessing (1) whether the dashboard comprehensively captures issues known to stakeholders and the administration that cause delays or errors in eligibility processing, (2) how the dashboard is being used as part of a process to set a time line for fixing the identified issues, and (3) opportunities for legislative oversight.
Current CalHEERS Dashboard Appears to Capture Known Issues Comprehensively. Based on our review of two iterations of the CalHEERS dashboard and information gathered from several meetings with the administration and stakeholders, the current CalHEERS dashboard appears to capture known defects and required additional functionalities related to Medi‑Cal eligibility and prioritize them for inclusion in CalHEERS releases. The dashboard identifies whether a Medi‑Cal eligibility functionality issue is the result of a system defect or a lack of additional functionality, explains the business impact of each issue, and targets a specific CalHEERS release for inclusion of each defect fix or additional functionality. Issues remain unresolved until deployed as part of a CalHEERS release, at which point county eligibility workers are required to confirm with the administration that issues are in fact resolved. Any additional issues that arise because of a CalHEERS release (such as a system defect caused by the addition of a new functionality) are added to the dashboard. While the majority of issues are targeted to be addressed in CalHEERS releases over the next 24 months (informing the 24‑month CalHEERS roadmap), some issues are scheduled to be addressed in a 2024 release once the state migrates from its current SAWS to a single system called the CalSAWS. The administration and stakeholders emphasize the iterative nature of the dashboard, which they view as a benefit of its design. Moreover, the current version of the dashboard appears comprehensive and suggests progress towards improved identification and prioritization of Medi‑Cal eligibility functionality issues in CalHEERS.
Frequent and Collaborative Engagement Between Administration and Stakeholders Has Helped to Clarify Issues to Be Resolved and Associated Time Lines to Address Issues. In addition to DHCS’s development of a dashboard, the administration also expanded CalHEERS Project Steering Committee membership to include the SAWS consortia; made the CalHEERS Project Steering Committee responsible for the continued development and maintenance of the dashboard; and then scheduled monthly meetings with DHCS, CWDA, and SEIU to review and update the dashboard. Based on our meetings with the administration and stakeholders, these changes have been positive for both the administration and stakeholders. Frequent collaboration to review and update the dashboard appears to clarify for both the administration and stakeholders what issues need to be resolved and on what time line. As defect fixes and new functionalities are deployed as part of CalHEERS releases, continued engagement will be necessary to determine whether issues are being resolved fully.
Recent Major CalHEERS Release Successfully Deployed, Includes Several Defect Fixes and Functionalities on Dashboard. The CalHEERS release successfully deployed on February 15, 2021 included five new sets of functionalities and eight defect fixes identified and prioritized on the dashboard. County eligibility workers are in the process of confirming with the administration whether these issues are in fact resolved. It is our understanding from stakeholders that the process will take several months to complete, so whether additional issues will arise from the CalHEERS release is unclear. The next CalHEERS release is scheduled for June 2021 and includes (as of March 2021) one new set of functionalities and seven defect fixes currently on the dashboard.
As subsequent CalHEERS releases are planned for deployment, the Legislature can use the releases as opportunities to evaluate whether the dashboard and associated process changes are adequately addressing Medi‑Cal eligibility functionality issues in CalHEERS.
Require Annual Report on CalHEERS System Releases. The Legislature could require the administration to report annually on the defect fixes and new functionalities on the dashboard that have been included in CalHEERS releases over the prior year. The report also could describe how the fixes and functionalities are designed to address known Medi‑Cal eligibility functionality issues in CalHEERS, and whether any new issues have been added to the dashboard because of the CalHEERS releases. Finally, the report could summarize results of the stakeholder process to confirm whether a release in fact addressed the issues it was designed to address. Annual monitoring of CalHEERS releases for inclusion of defect fixes and new functionalities on the dashboard would provide the Legislature the opportunity to evaluate the effectiveness of the dashboard and associated process changes.
Direct DHCS to Develop a Less Technical, More Focused Version of CalHEERS Dashboard to Facilitate Legislative Oversight. The Legislature also could direct DHCS to develop a less technical version of the CalHEERS dashboard to show the Legislature—in a user‑friendly and focused way—how fixes and functionalities on the dashboard would improve Medi‑Cal eligibility processes. The current version of the CalHEERS dashboard does appear to capture defects and functionalities related to Medi‑Cal eligibility and prioritize them in future CalHEERS releases. However, the language and organization of the dashboard is very technical, and does not directly connect the resolution of one or more system defects or the addition of new system functionalities to, for example, goals for the Medi‑Cal program. A simplified version that explicitly shows how the resolution of issues on the dashboard would, for example, decrease the amount of time required for county eligibility workers to determine program eligibility would help inform the Legislature’s oversight of the dashboard and associated process changes going forward.