Quality ManagementMedicaidMay 9, 2023

Initial Health Appointment

Effective January 1, 2023, the Initial Health Assessment was retired by the Department of Health Care Services (DHCS) and replaced with the Initial Health Appointment (IHA), as addressed in DHCS All Plan Letter APL 22-030 Initial Health Appointment. The IHA is fundamental to the California Advancing and Innovating Medi-Cal (CalAIM) Basic Population Health Management (BPHM) program as referenced in DHCS APL 22-024 Population Health Management Policy Guide.

Performed by a primary care provider (PCP) within the primary care medical setting, the IHA promotes member health by establishing a medical home and leveraging culturally and linguistically appropriate primary care to improve healthcare disparities. PCPs shall ensure the provision of an Initial Health Appointment (IHA) within 120 days of plan enrollment. For members of all ages, the PCP comprehensively assesses:

  • Past physical, social, behavioral health history, and
  • Current acute and chronic conditions, including review of organ systems, dental assessment, developmental screenings, and
  • Diagnosis and plan of care for any needs, conditions, and identified diseases.

During the IHA, the PCP:

  • Identifies risks;
  • Assesses need for preventive screens/services and plans appropriate follow-up;
  • Identifies those members whose health needs require coordinated services with appropriate community resources, including other agencies; and
  • Assists with navigation and coordination of referrals for health, health education, dental, social services, benefit programs, and level of care coordination.

PCPs are required to review their monthly eligibility list provided by their primary medical group/independent practice association, or via Availity Essentials* for certain PCPs, to proactively contact their assigned members and encourage scheduling an IHA within required time frames, including providing referral to the Anthem Blue Cross (Anthem) transportation vendor as needed, making reasonable attempts to contact a member. As evidence that an IHA was attempted, the Anthem Provider Manual instructs providers to document in the medical record all unsuccessful contact and scheduling attempts, missed appointments, or the member’s refusal to schedule an IHA. An IHA may be waived if a PCP determines that the member’s medical record contains complete and current information consistent with the requirements within the last 12 months.

DHCS will measure both primary care visits and childhood screenings.

What does this change mean for providers?

Initial screenings: The Health Information Form (HIF)/Member Evaluation Tool (MET)is a screening tool that is required to be completed by new members within 90 days of enrollment with Anthem. Members submit their completed screeners to Anthem Care Management staff who follow-up with members on positive screener responses and encourage follow-up with the PCP, as needed.

Individual Health Education Behavior Assessment (IHEBA) and Staying Healthy Assessment (SHA) [RETIRED]: The IHEBA/SHA were retired on January 1, 2023.As a result, all screenings and assessments addressed by completing an SHA are to be completed by the PCP using standardized assessment tools, in a culturally and linguistically appropriate manner that seek to define the member’s risk factors and problems; determine a member’s needs, preferences, health goals and priorities; and aid in the development of treatment recommendations, referrals and follow-up as documented in the medical record. Tools include, but are not limited to, age appropriate screenings for any required age-specific screenings such as Adverse Childhood Experiences (ACEs); developmental progress and autism; vision and hearing; brief emotional/behavioral assessments and health behavior assessments and interventions; SABIRT, depression, substance use disorder (SUD), and postpartum mood disorder screening; tobacco cessation counseling and screening for referral to the Diabetic Prevention Program and cognitive assessment.

Dental screenings/oral health assessments for all members: As part of the IHA, PCPs provide an initial dental screening/oral health assessment for all members and refer to a dental provider to address any immediate dental needs and for comprehensive dental care. For members under the age of 21, a dental screening/oral health assessment must be performed as part of every periodic assessment, with dental referrals made for members no later than 12 months of age or when a referral is indicated based on assessment. Fluoride varnish, including when provided by a PCP, and oral fluoride supplementation assessment and provision must be consistent with the AAP/Bright Futures periodicity schedule and anticipatory guidance. PCPs must also ensure that members are referred to appropriate Medi-Cal Managed Care (Medi-Cal) dental providers.

Preventive screenings: PCPs are accountable for providing preventive screenings for children and adolescents as recommended by the most recent American Academy of Pediatrics/Bright Futures age-specific guidelines and periodicity schedule(AAP) and for adults, as recommended by the Guide to Clinical Preventive Services of the US Preventive Services Task Force Grade A and B recommendations for providing preventive services, testing, and counseling services(USPSTF). However, DHCS no longer requires all of these elements to be completed during the initial appointment, so long as members receive all required screenings in a timely manner consistent with guidelines.

Initial Health Appointments for members under 21 years of age: IHA services for all newly enrolled members under age 21 will conform to the most recent AAP periodicity schedule — for children less than 18 months of age, the IHA must be completed within AAP periodicity schedules for age 2 and younger. For members between 18 months up to 21 years of age, the IHA must be completed according to the AAP periodicity schedule, but no later than 120 days of enrollment. The IHA is inclusive of the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit, as referenced in APL 23-005 EPSDT(referred to as Medi-Cal for kids and teens by DHCS), and provides comprehensive and preventive healthcare services, and referrals for medically necessary care. EPSDT is key to ensuring that children and adolescents receive appropriate preventive, dental, mental health, and developmental, and specialty services.The IHA includes immunizations specified by the Advisory Committee on Immunization Practices (ACIP) childhood immunization schedule to ensure that the child is up to date for their age. Practice standards include age‑appropriate health education and anticipatory guidance.

Initial Health Appointments for members 21 years of age and older: IHA services provided to members aged 21 years of age and older are completed in accordance with Anthem’s Preventive Health Care Guidelines (found on Anthem’s provider website), which are based on the most current edition of the USPSTF, and in conformance with Title 22, CCR, Section 53910.5(1)(1) for adults. The IHA provides the PCP with an opportunity to perform well-adult care including identification of issues and risks using standardized assessment tools and referral for health education and behavioral health services, and an assessment of the need for preventive screens or services, and corresponding referrals. This includes providing well-woman exams (including cervical cancer screening) and referral of members for related services, such as breast cancer screening.

Perinatal services: Perinatal services may be part of an IHA, with services provided according to the most current standards of the American College of Obstetrics and Gynecology.

Telehealth: Where appropriate, PCPs who have implemented telehealth may provide appropriate elements of the IHA exam virtually, followed by a timely in-person visit. Providers are strongly encouraged to have an in‑place process to monitor and ensure scheduling and completion of the in-person component of the IHA visit. The telehealth and secondary in-person visits are considered part of the same well-visit exam and may only be billed for once, at the completion of the telehealth component.

Medical record documentation: Medical record documentation follows standards in the Anthem Provider Manual, including annotation of culturally and linguistically appropriate primary and preventive care; history and physical assessment and diagnosis, including prenatal care; laboratory or other diagnostic services, and plan for further evaluation and treatment of any identified diseases or conditions including referrals for any abnormal findings. Documentation includes preventive services provided in conformance with schedules and guidelines; immunizations; blood lead and other screenings with health education and anticipatory guidance. Include results of standardized assessment tools and identification of issues and risks and appropriate referrals for required services, including Dyadic and behavioral health services. Document all contact attempts to schedule and the reason for no visit (for example, member’s refusal, missed appointment). Documentation of attempts to schedule an IHA is considered evidence in meeting this requirement.

Referral resources: Anthem’s Provider Manual includes listings of many IHA-appropriate referral contacts, including, the Women’s Infants and Children (WIC) Program; CA Children’s Services (CCS); Regional Centers and more.

Code your services correctly: The list of IHA-compliant codes may be found on the Anthem provider website at https://providers.anthem.com/california-provider/home. These codes are informational only; this information does not guarantee reimbursement.

References:

* Availity, LLC is an independent company providing administrative support services on behalf of the health plan.

CABC-CD-023503-23