Requirements

All new Medi-Cal members must receive an initial health appointment (IHA), which includes an age-appropriate history and physical examination, within 120 calendar days after their date of enrollment. The IHA must be conducted in a culturally and linguistically appropriate manner for all members, including those with disabilities.

The member may be seen initially during a visit for episodic care. Regardless of the reason for the initial visit, the PCP should conduct the IHA at the first health care contact and document the assessment in the medical record.

IHA Guidelines

For members age 21 and older, the IHA must follow the Department of Health Care Services (DHCS) guidelines and Health Net preventive care services guidelines. The preventive care guidelines in the Guide to Clinical Preventive Services (U.S. Preventive Service Task Force) are considered the minimum acceptable standards for adult preventive care services. A member's risk factors affect the type and quantity of preventive services needed. A member may need additional services at more frequent intervals.

For members age 21 and older, the initial appointment includes:

• Complete history, including immunization status, dental health, sexual behavior, alcohol, tobacco and drug use, diet, and exercise habits.
• Physical examination, including height, weight and blood pressure.
• Cholesterol screening beginning at age 45 for women, age 35 for men and earlier for men and women if risk factors are present.
• Tuberculosis screening including a Mantoux skin test on all persons determined to be at high risk.

For women, the initial appointment must also include:

• Clinical breast examination for women over age 40.
• Mammograms according to U.S. Preventive Services Task Force (USPSTF) guidelines.
• Cervical cancer screening, such as Pap test, at least every three years for women with a cervix from the onset of sexual activity or age 21 (whichever comes first) to age 65. Women over age 65 should be screened at the provider's discretion based on risk.
• Chlamydia screening for all sexually active females age 21 and older in accordance with the most recent Centers for Disease Control and Prevention (CDC) guidelines.
• Bone density screening routinely for women ages 65 and older, and for women age 60 at increased risk.

For members under age 21, the IHA and ongoing assessments must follow the requirements of the Child Health and Disability Prevention (CHDP) program.

For members under ages 21, the IHA includes:

• Health and developmental history.
• Unclothed physical examination, including appointment of physical growth.
• Assessment of nutritional status.
• Inspection of ears, nose, mouth, throat, teeth, and gums.
• Vision screening.
• Hearing screening.
• Tuberculosis testing and laboratory tests appropriate to age and sex, including tests for anemia, diabetes and urinary tract infections.
• Sexually transmitted disease (STD)/sexually transmitted infection (STI) screening as appropriate.
• Testing for sickle cell trait and lead poisoning where appropriate. Health Net covers the provision of blood lead screening tests for members at 12 and 24 months and is committed to making every effort to inform and educate providers and members about the importance of preventing and detecting elevated blood lead levels.
• Administration of immunizations appropriate to age and health history as necessary to make status current.
• Health education behavioral risk assessment, risk reduction and anticipatory guidance counseling, identifying members whose health needs require coordination with appropriate community resources and other agencies for services not covered under Health Net's Medi-Cal contract, referral and follow up.
• As necessary, CHDP providers make referrals to the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) for children up to age five, referrals to dentists for preventive or restorative care, and referrals to medical providers.

For both adults and children, the IHA must include health education behavior assessments to determine health practices, values, behaviors, knowledge, attitudes, beliefs, culturally specific practices, literacy levels, and health education needs.

Members Under Age 21

For all providers, a member eligibility report is available through Health Net Membership Accounting at the primary care physician's (PCP's) request to allow providers to reach out to their new members and ensure completion of all appropriate preventive care services and the IHA within 120 calendar days. Providers may log on to Health Net's provider portal to access the online IHA reports located under Provider Reports.

Health Net reviews monthly claims and encounter data of initial health appointment rendered by participating providers. These encounters are cross-checked against member enrollment data. A member eligibility report is available at the PCP's or participating physician group's (PPG's) request on a monthly basis to provide an aid for IHA compliance.

In all cases, the PCP must document all member contacts, including scheduling of the appointment or the member's refusal to schedule an appointment, in the member's medical record.

Refugee Health Assessment

In all cases, the PCP must document all member contacts, including scheduling of the appointment or the member's refusal to schedule an appointment, in the member's medical record.

Members in the Refugee Assistance program should have received a refugee health assessment prior to enrolling in a Health Net plan through the Refugee Assistance program. To inform the medical home and ensure medical records are as complete as possible, providers are reminded to request these documents from the Refugee Health Program at the member's county of residence.

Health Net's public programs administrators assist in the transfer of medical information to the primary care physician (PCP) for newly enrolled members previously enrolled in the Refugee Assistance program as needed.

Childhood Blood Lead Screening

Providers must follow guidelines issued by the Department of Public Health's California Childhood Lead Poisoning Prevention Branch (CLPPB) Health and the California Childhood Lead Poisoning Prevention Branch (CLPPB)-issued guidelines on childhood blood lead screening, which includes CDC Recommendations for Post-Arrival Lead Screening of Refugees, of the Department of Public Health and also:

• Provide oral or written guidance to the parents or guardians of a child that includes information that children can be harmed by exposure to lead. The guidance must be provided at each periodic health assessment for ages 6-72 months.
• Perform blood lead level (BLL) testing on all children as follows:
  • At ages 12 months and 24 months.
  • When the provider performing the periodic health assessment becomes aware that a child age 12-24 months has no documented evidence of a BLL test taken at age 12 months or thereafter.
  • When the provider becomes aware that a child age 24-72 months has no documented evidence of BLL test results taken at age 24 months or thereafter.
  • Whenever the provider becomes aware that a child age 12-72 months has had a change in circumstances that places the child at increased risk of lead poisoning, in the provider's professional judgement.
  • When requested by the parent or guardian.
• The health care provider is not required to perform BLL testing in the following cases. The reasons for not screening must be documented in the child's medical record.
  • The parent or guardian refuses consent for the screening. Providers must obtain a signed statement of voluntary refusal by the parent or guardian, or document reasons for not obtaining the signed statement (i.e. parent refused or is unable to sign, assessment done via telehealth, etc.).
  • If in the professional judgement of the provider, the risk of screening poses a greater risk to the child's health than the risk of lead poisoning.

Blood lead level screening must be reported.

• Encounter or claims data is used to track the administration of blood level screenings. Providers must ensure that encounters are identified using the appropriate CPT codes for blood level screenings.
• Laboratories and health care providers performing blood lead analysis on specimens are to electronically report all results to CLPPB, with specified patient demographics, ordering physician and analysis data on each test performed. Information on how to report results to CLPPB can be found at CLPPB website.