BILL ANALYSIS �
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: SB 964
AUTHOR: Hernandez
AMENDED: April 9, 2014
HEARING DATE: April 30, 2014
CONSULTANT: Boughton
SUBJECT : Health care service plans: timeliness standards:
medical surveys.
SUMMARY : Requires health plans to use standardized survey
methodology, if developed by the Department of Managed Health
Care (DMHC), for timely access reporting. Repeals an
exemption from DMHC medical surveys for Medi-Cal managed care
plans, as specified. Requires a County Organized Health
System to be treated as a health plan under specified timely
access requirements. Requires DMHC medical surveys to be
conducted by distinct product lines for Medi-Cal managed care
and Covered California products, and requires for those
product lines annual reviews for compliance with network
adequacy, timely access, continuity of care, and quality
management. Exempts from the distinct review by product line
requirement plans that use the same network for Medi-Cal or
Covered California products. Requires annual DMHC medical
surveys for the first five years after initial enrollment for
Medi-Cal managed care plans that enroll beneficiaries as a
result of the transition of the Healthy Families Program,
seniors and persons with disabilities, rural expansion, and
the Coordinated Care Initiative.
Existing law:
1.Establishes DMHC to regulate health plans under the
Knox-Keene Health Care Service Plan Act of 1975 (Knox-Keene
Act), the California Department of Insurance (CDI) to
regulate health insurers under the Insurance Code and
Department of Health Care Services (DHCS) to administer the
Medi-Cal program, which provides health care to children,
seniors, persons with disabilities (SPDs), people also
eligible for Medicare and low-income individuals and
families.
2.Requires DMHC to develop and adopt regulations to ensure
that health plan enrollees have access to health care
services in a timely manner, and requires DMHC to develop
Continued---
SB 964 | Page 2
indicators of timeliness and consider the following:
a. Waiting times for appointments with
physicians and specialists;
b. Timeliness of care in an episode of illness,
including timeliness to referrals; and,
c. Waiting time to speak to a physician,
registered nurse or other qualified health
professional.
3.Requires DMHC to consider the needs of rural areas,
specifically those in which health facilities are more than
30 miles apart and any requirements imposed by DHCS on
health care service plans that contract to provide Medi-Cal
managed care.
4.Requires contracts between health plans and health care
providers to assure compliance with the timely access
standards developed by DMHC. Requires the contracts to
require reporting by health care providers to health plans
and by health plans to DMHC to ensure compliance with the
standards.
5.Requires health plans to report annually to DMHC on
compliance with the timely access standards
6.Requires DMHC to work with the Office of the Patient
Advocate to assure that the quality of care report card
incorporates information provided regarding the degree to
which health plans and health care providers comply with the
requirements of timely access to care.
7.Requires DMHC to review information regarding compliance
with the timely access standards and to make recommendations
for changes that further protect enrollees.
8.Requires DMHC to conduct periodically an onsite medical
survey of the health care delivery system of each plan.
Requires the survey to include a review of the procedures
for obtaining health services, the procedures for regulating
utilization, peer review mechanisms, internal procedures for
assuring quality of care, and the overall performance of the
plan in providing health care benefits and meeting the
health care needs of subscribers and enrollees.
9.Requires DMHC medical surveys to be conducted as often as
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necessary, but not less frequently than once every three
years.
10.Requires, to avoid duplication, the DMHC director to
employ, but not be bound by, the findings of DHCS medical
surveys, for health plans contracting with DHCS, as
specified.
11.Requires, no later than 18 months following release of a
final medical survey report, DMHC to conduct a follow up
review to determine and report on the status of the plan's
efforts to correct any deficiencies.
12.Exempts, notwithstanding 8) through 11), any health plan
that provides services solely to Medi-Cal beneficiaries from
being subject to 8) through 11) upon submission to the DMHC
director of the medical survey audit for the same period
conducted by the DHCS as part of the Medi-Cal contracting
process, unless the DMHC director determines that an
additional medical survey audit is required.
13.Requires DHCS to conduct annual medical audits of each
Medi-Cal managed care plan unless the DHCS director
determines there is good cause for additional reviews.
Requires the reviews to use the standards and criteria
established pursuant to the Knox-Keene Act, or Insurance
Code, as appropriate. Requires, except in those instances
where major unanticipated administrative obstacles prevent,
or after a determination by the DHCS director of good cause,
the reviews to be scheduled and carried out jointly with
reviews carried out pursuant to the Knox-Keene Act, or the
Insurance Code, as appropriate, if reviews under either act
will be carried out within time periods, which satisfy the
requirements of federal law.
14.Requires DHCS to be authorized to contract with
professional organizations or DMHC or CDI, as appropriate,
to perform the periodic review required by law. Requires
DHCS, or its designee, to make a finding of fact with
respect to the ability of the Medi-Cal managed care plan to
provide quality health care services, effectiveness of peer
review, and utilization control mechanisms, and the overall
performance of the Medi-Cal manage care plan in providing
health care benefits to its enrollees.
SB 964 | Page 4
15.Requires the CDI Commissioner, on or before January 1,
2004, to promulgate regulations applicable to health
insurers to ensure that insureds have the opportunity to
access needed health care services in a timely manner.
Requires these regulations to be designed to assure
accessibility of provider services in a timely manner to
individuals comprising the insured or contracted group
pursuant to the benefits covered. Requires the regulations
to assure:
a. Adequacy of number and locations of
providers in relationship to size and location of
group and that services are available at reasonable
times;
b. Adequacy of number and license
classifications in relationship to projected demand;
c. The policy or contract is not inconsistent
with standards of good health and clinically
appropriate care; and,
d. All contracts are fair and reasonable.
16.Requires pursuant to regulation, in determining whether an
insurer's arrangements for network provider services comply
with the regulations, the Commissioner to consider to the
extent the Commissioner deems necessary, the practices of
comparable plans licensed under the Knox-Keene Act.
This bill:
1.Requires health plans to use standardized survey methodology
if developed by DMHC for timely access reporting.
2.Requires DMHC to annually review information regarding
compliance with the timely access standards, including any
waivers or alternative standards granted to a plan.
Requires by December 1, 2016, and annually thereafter, DMHC
to post its findings from that review on its Internet
Website.
3.Repeals a provision in the Knox-Keene Act that exempts a
health plan that provides services only to Medi-Cal
beneficiaries from medical survey requirements upon
submission to the director of DMHC of the medical survey
audit for the same period conducted by DHCS as part of the
Medi-Cal contracting process, unless the director determines
that an additional medical survey audit is required.
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5
4.Requires a health plan that provides services to Medi-Cal
managed care beneficiaries to receive DMHC medical surveys
by its Medi-Cal managed care product line distinct from its
other product lines, if any, in order to determine whether
services received by Medi-Cal beneficiaries comply with the
Knox-Keene Act.
5.Requires these health plans to be annually reviewed with
respect to Medi-Cal managed care product lines for
compliance with:
a. Accessibility and availability of services,
including network adequacy and timely access to care;
b. Continuity of Care; and,
c. Quality management, including precautions to
ensure that appropriate care is not withheld or delayed
for any reason.
6.Requires a health plan that provides services to enrollees
in Covered California to receive DMHC medical surveys by its
product line sold through Covered California distinct from
is product line sold outside Covered California, if any, in
order to determine whether the services received by Covered
California enrollees comply with the Knox-Keene Act.
7.Requires these health plans to be annually reviewed with
respect to product line sold through Covered California for
compliance with:
a. Accessibility and availability of services,
including network adequacy and timely access to care;
b. Continuity of Care; and,
c. Quality management, including precautions to
ensure that appropriate care is not withheld or delayed
for any reason.
8.Exempts from the DMHC medical survey distinct product
requirement a health plan that uses the same network for its
product line sold through Covered California as the network
used for its product line sold outside Covered California
and a health plan that uses the same network for its product
line sold through Covered California as the network used for
its Medi-Cal managed care product line.
9.Requires annual DMHC medical surveys with respect to the
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populations enrolled for the first five years after initial
enrollment for a plan that enrolls Medi-Cal beneficiaries as
a result of:
a. The transition of Healthy Families Program;
b. Managed care expansion of SPDs;
c. Managed care expansion in rural counties; and,
d. The Coordinated Care Initiative.
10.Authorizes DMHC to coordinate the surveys and reviews with
DHCS in order to allow for simultaneous oversight of
Medi-Cal managed care plans by both departments, provided
that this coordination does not result in a delay of the
surveys or reviews required or in the failure of DMHC to
conduct those surveys or reviews.
11.Requires a County Organized Health System to be treated as
a health care service plan under the timely access
requirements to report by health care providers and health
plans and report annually to DMHC on compliance.
FISCAL EFFECT : This bill has not been analyzed by a fiscal
committee.
COMMENTS :
1.Author's statement. According to the author, this bill has
been introduced to ensure that the DMHC medical surveys take
into consideration requirements unique to Medi-Cal managed
care and Covered California and that sufficient attention
and resources are given to health plan network adequacy and
timely access enforcement. Media reports have raised
concerns about lack of access to health care providers and
"narrow" provider networks in Medi-Cal and Covered
California. Covered California has also reported questions
about accuracy of provider directories, timely access calls
in certain areas or "hot spots," and confusion about
mismatch of physicians and hospitals, physician confusion
about network status and confusion about benefit design.
California has strong network adequacy and timely access to
services requirements for health plans and insurers but
monitoring and enforcement of these laws is developing at
the same time millions of new individuals are enrolling in
Medi-Cal managed care and Covered California plans. Covered
California has recommended coordinating directly with
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regulators on network adequacy, requiring the use of the
regulator template, common analytics and coordinated product
and network filing reviews with cross plan comparisons. DMHC
also indicates that over the last 18 months significant
complaint increases with regard to access related to Covered
California and Medi-Cal include enrollees having difficulty
finding a provider that is contracted with their plan. This
bill is intended to clarify distinctions in enforcement
responsibility and ensure tools are in place so that DMHC
can monitor and enforce adequate network and timely access
requirements. Having an insurance card only ensures better
health outcomes if patients actually have access to the
right care at the right place at the right time.
2.Legislative Analyst Analysis. As described in the LAO's
analysis of the Governor's 2014-15 Budget, managed care is
increasingly becoming the dominant delivery system in the
Medi-Cal program as both the number and the percentage of
Medi-Cal beneficiaries enrolled in managed care continues to
grow. Roughly 73 percent (about 7.5 million Medi-Cal
beneficiaries) will be enrolled in managed care in 2014-15.
The increase in managed care enrollment reflects transitions
of beneficiaries from fee-for-service to managed care, as
well as additional enrollees associated with the transfer of
the Healthy Families Program and implementation of the
Affordable Care Act (ACA), see table from LAO analysis
below.
Recent and Upcoming Transitions to Medi-Cal Managed Care
Through 2014-15
---------------------------------------------------------
|Population |Approximate |Time Frame |
| |Enrollment | |
|----------------------+-------------------+--------------|
|Medi-Cal SPDs |240,000 |June |
| | |2011-May |
| | |2012 |
|----------------------+-------------------+--------------|
|HFP to Medi-Cal |850,000 |Jan - Nov |
| | |2013 |
|----------------------+-------------------+--------------|
|Rural expansion to |400,000 |Sept - Nov |
|28 counties | |2013 |
|----------------------+-------------------+--------------|
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|ACA optional |780,000 |Beg Jan |
|expansion | |2014 |
|----------------------+-------------------+--------------|
|Coordinated Care |450,000 |Beg April |
|Initiative dual | |2014 |
|eligible | | |
|----------------------+-------------------+--------------|
| |2,720,000 | |
---------------------------------------------------------
According to the LAO, both the Knox- Keene Act and Medi-Cal
contracts contain a variety of requirements intended to
ensure that managed care plans are providing enrollees with
adequate access to care. For example, regulations
implementing the Knox- Keene Act establish three main
categories of standards that plans must follow to
demonstrate adequate access. These are: (1) minimum ratios
of full-time equivalent providers to enrollees; (2) maximum
distances between primary care providers and enrollees'
residences and workplaces; and, (3) limits on enrollee wait
times for appointment and referrals. (The first two
categories of requirements are often referred to as "network
adequacy" standards and geographic standards, while the
third category is a set of recently developed regulations
known as "timely access" standards.) DHCS monitors
additional contract-specific requirements related to access,
often with the DMHC's assistance under interagency
agreements. These additional requirements may account
for-among other areas-the number of network providers who
are not accepting new patients, the location and types of
specialists within the network (with specific requirements
that depend on the characteristics and health needs of the
plan's enrollees), and coverage of out-of-network services
that the plan may be unable to provide. Both departments
conduct various activities to monitor access to care,
including quarterly reviews of provider network data
submitted by plans, help lines that may identify early
access problems through beneficiary complaints, and periodic
on-site audits of plans' operations. The LAO raises
questions regarding DMHC's implementation of Knox-Keene Act
standards, such as (1) how plans demonstrate timely access
and (2) whether current provider-to-enrollee ratios
meaningfully reflect network adequacy.
3.DMHC and CDI Timely Access. The DMHC's Timely Access to
Non-Emergency Health Care Services Regulation (Timely Access
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Regulation) became effective January 17, 2010. The purpose
of the Timely Access Regulation, is to fully implement AB
2179 (Cohn), Chapter 797, Statutes of 2002, which directed
DMHC and CDI to adopt regulations to ensure enrollees access
to necessary health care services in a timely manner. The
health plans licensed by DMHC had until January 17, 2011 to
fully implement the policies, procedures and systems
necessary to comply with the regulations. In October 2010,
health plans were required to submit a filing to demonstrate
how the standards and regulations would be met. Each health
plan must show that its provider network is large and varied
enough to offer enrollees appointments that meet the
following standards:
a. The clinical appropriateness standard requires
that enrollees be offered appointments for covered
health care services within a time period appropriate
for their condition; and,
b. Quality assurance standards requiring that
enrollees be offered appointments within the following
time-elapsed standards:
i. Within 48 hours of a request for an
urgent care appointment for services that do not
require prior authorization;
ii. Within 96 hours of a request for an
urgent appointment for services that do require
prior authorization;
iii. Within 10 business days of a request
for non-urgent primary care appointments;
iv. Within 15 business days of a request
for an appointment with a specialist;
v. Within 10 business days of a request
for an appointment with non-physician mental
health care providers; and,
vi. Within 15 business days of a request
for a non-urgent appointment for ancillary
services for the diagnosis or treatment of injury,
illness, or other health condition.
The Timely Access Regulation also requires health plans to
provide or arrange for the provision of 24/7 telephone
triage or screening services, as defined for patients to
obtain timely assistance in determining the urgency of their
SB 964 | Page 10
condition, including a reasonable call back time (not more
than 30 minutes). Beginning in March 2012, health plans must
also file an annual compliance report. The annual compliance
report includes compliance rates for each of the
time-specific standards. Plans must monitor network
compliance with the standards, and must investigate and
correct deficiencies. Specialized plans licensed by DMHC
are subject to the Timely Access Regulation but to a lesser
extent than the full service health plans. DMHC informs
plans that their interpretation of the full time equivalent
basis and 1:2,000 means that a primary care provider cannot
be assigned more than 2,000 enrollees based upon all plans
and product types that primary care provider contracts to
accept. The DMHC has only recently begun receiving reliable
data that can be used to determine what the impact is for
primary care providers that contract with multiple plans and
for multiple lines of business. With this new data, DMHC
indicates it will be able to better analyze primary care
providers to enrollee ratios and work with plans to ensure
compliance.
CDI Timely Access Regulations require in arranging for
network provider services, insurers to ensure that:
a. There is the equivalent of at least one
full-time physician per 1,200 covered persons and at
least the equivalent of one full-time primary care
physician per 2,000 covered persons;
b. There are primary care network providers
with sufficient capacity to accept covered persons
within 30 minutes or 15 miles of each covered
person's residence or workplace;
c. There are medically required network
specialists who are certified or eligible for
certification by the appropriate specialty board
with sufficient capacity to accept covered persons
within 60 minutes or 30 miles of a covered person's
residence or workplace. Notwithstanding the above,
the Commissioner may determine that certain medical
needs require network specialty care located closer
to covered persons when the nature and frequency of
use of such health care services, support such
modification;
d. There are mental health professionals with
skills appropriate to care for the mental health
needs of covered persons and with sufficient
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11
capacity to accept covered persons within 30 minutes
or 15 miles of a covered person's residence or
workplace;
e. There is a network hospital with sufficient
capacity to accept covered persons for covered
services within 30 minutes or 15 miles of a covered
person's residence or workplace;
f. Notwithstanding the above, these
requirements are not intended to prevent the covered
person from selecting providers as allowed by their
insurance contract beyond the applicable geographic
area specified by these standards; and,
g. If an insurer is unable to meet the network
access standard(s) due to the absence of practicing
providers located within sufficient geographic
proximity of the insurer's covered persons, the
insurer may apply to the Commissioner for a
discretionary waiver of any network access standard
for the applicable geographic area. Such application
should include, at a minimum, a description of the
affected area and covered persons in that area and
how the insurer determined the absence of practicing
providers.
4.Interagency Agreements. The table below highlights DMHC's
responsibilities under the interagency agreements (IAs) with
DHCS. A fourth IA on the rural expansion has not yet been
finalized between the two departments.
-----------------------------------------------------------------
|Authority |Welfare and |Welfare and |AB 1467 |
| |Institutions |Institutions | |
| |Code Section |Code | |
| |14183.6 |14132.275(p) | |
|------------+----------------+------------------+----------------|
|Program |1115 Waiver |CCI |Dental |
|or |Bridge to | | |
|Population |Reform (SPDs) | | |
|s | | | |
|------------+----------------+------------------+----------------|
|Time |Jan 1, |July 1, 2013 - |Sept 1, 2013 |
|frame of |2011-June 30, |June 30, 2016 |- June 30, |
|Scope of |2013 | |2015 |
SB 964 | Page 12
|Work |extension to | | |
| |June 30,2014 | | |
|------------+----------------+------------------+----------------|
|Contract |$2,909,000 |$3,295,000 |$346,500 |
|Amount | | | |
|------------+----------------+------------------+----------------|
|DMHC | | | |
|Contract | Financial | Operational | Financial |
|Requiremen | Audits | Readiness | Audits |
|ts | (once | (first and | (once |
| | every | second | every |
| | three | quarters | three |
| | years) | of 2013) | years) |
| | | | |
| | Network | Financial Audits | Dental Surveys |
| | Adequacy | (once | (once |
| | (quarterl | every | every |
| | y) | three | three |
| | Includes | years) | years) |
| | assessmen | Network | Includes |
| | ts, | Adequacy | provider/ |
| | changes | (review | dentist |
| | in | contractual | ratios |
| | enrollmen | | and |
| | t, | obligations | geographi |
| | network | ) | c and |
| | changes, | Medical | timely |
| | geo | Surveys | access |
| | access, | (once | to care |
| | network | every | policies |
| | providers | three | and |
| | not | years) | procedure |
| | accepting | |s |
| | new | Consumer | |
| | patients, | Assistance | |
| | access | | |
| | related | | |
| | feedback | | |
| | from | | |
| | enrollees | | |
| | . | | |
| | | | |
| | Medical | | |
| | Surveys | | |
| | (once | | |
| | every | | |
SB 964 | Page
13
| | three | | |
| | years) | | |
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1.Covered California. At Covered California's April 17, 2014
board meeting, staff reviewed its contractual expectations
for quality and access and shared with the board and public
concerns being raised about the accuracy of certain plan
provider directories, timely access to available providers,
including specialists and call hot spots in rural counties
and in Alameda County. Confusion about benefit design with
regard to in-network vs out-of-network benefits was
described as well as mismatch of physicians and hospitals.
Covered California staff explained that they are
troubleshooting with plan partners and referring enrollees
to DMHC and independent legal assistance through the Health
Consumer Alliance. Covered California indicates they have
been proactive with plans and provider organizations in
trying to communicate changes and add physicians to
networks. Covered California is working to optimize timely
access and is considering methods such as sponsoring a third
party "secret shopper" survey.
2.County Organized Health Systems. In California, the oldest
model of Medi-Cal managed care is the County Organized
Health System, which serves approximately 1.3 million
beneficiaries through six health plans in 14 counties:
Marin, Mendocino, Merced, Monterey, Napa, Orange, San Mateo,
San Luis Obispo, Santa Barbara, Santa Cruz, Solano, Sonoma,
Ventura, and Yolo. In the County Organized Health System
model, DHCS contracts with a health plan established by the
county's Board of Supervisors and all Medi-Cal enrollees are
in the same health plan. Unlike other Medi-Cal managed care
plans, County Organized Health Systems are exempt from
licensure under the Knox-Keene Act and are therefore not
regulated by DMHC, but are required to meet most of the
Knox-Keene requirements by contract with DHCS.
3.Related legislation. AB 2533 (Ammiano) requires health plans
and insurers unable to meet timely access standards through
contracted providers to arrange for the provision of
services by a non-contracting provider, as specified, and
requires CDI to adopt new timely access standards for health
insurers in accordance with statutory criteria similar to
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those applicable to health plans under DMHC. AB 2533 is
pending in Assembly Health Committee.
SB 1100 (Hernandez) would allow people with individual
health insurance coverage who are in the middle of treatment
for certain conditions, such as cancer or a pregnancy, when
they make a health plan change to complete the treatment
even if their provider is not in the new health plan's
network. This bill also requires notice of the process to
request completion of covered services to be provided in
every disclosure form, as specified, and in any evidence of
coverage issued after January 1, 2015. SB 1100 passed the
Senate Heal Committee by a vote of 7-1, on April 24, 2014.
8.Prior legislation. SB 94 (Committee on Budget and Fiscal
Review), Chapter 37, Statutes of 2013, requires DHCS to
enter into an interagency agreement with DMHC to have DMHC,
on behalf of the DHCS, conduct financial audits, medical
surveys, and a review of the provider networks of the
managed care health plans participating in the federal
waiver demonstration project and the Medi-Cal managed care
expansion into rural counties, and to provide consumer
assistance to beneficiaries, as specified. Requires the
interagency agreement to be updated, as necessary, on an
annual basis in order to maintain functional clarity
regarding the roles and responsibilities of these core
activities. Prohibits DHCS from delegating its authority as
the single state Medicaid agency to DMHC. SB 94 also
requires DHCS to enter into an interagency agreement with
DMHC to perform some or all of DHCS' oversight and readiness
review activities for the CCI, as specified. These
activities may include providing consumer assistance to
beneficiaries and conducting financial audits, medical
surveys, and a review of the adequacy of provider networks
of the participating managed care health plans. Requires the
interagency agreement to be updated, as necessary, on an
annual basis in order to maintain functional clarity
regarding the roles and responsibilities of DMHC and DHCS.
Prohibits DHCS from delegating its authority under this
section as the single state Medicaid agency to DMHC.
AB 1467 (Committee on Budget), Chapter 23, Statutes of 2012,
among other provisions addresses Medi-Cal Dental Managed
Care in Sacramento and Los Angeles counties. Provides for
the establishment of a stakeholder advisory committee to
provide input on the delivery of oral health and dental care
SB 964 | Page
15
services in Sacramento County. Provides the Director of
DHCS with the authority to establish a beneficiary dental
exception process in which Medi-Cal beneficiaries
mandatorily enrolled in dental health plans in Sacramento
County can move to fee-for-service Denti-Cal. Establishes a
list of performance measures to ensure that dental health
plans meet quality criteria, and requires an interagency
agreement with DMHC.AB 1457 also provides for the expansion
of Medi-Cal managed care into the 28 rural counties that are
now fee-for-service. This proposal will result in General
Fund savings of $2.7 million in 2012-13.
AB 2179 (Cohn), Chapter 797, Statutes of 2002, requires DMHC
and CDI to develop and adopted regulations to ensure that
enrollees have access to needed health care services.
9.Support. Health Access California sponsors this bill
indicating for more than twenty years, directors of DHCS
have assured lawmakers, advocates, and other stakeholders
that those Californians covered through Medi-Cal managed
care would have the same protections as every other
Californian in a managed care plan. Yet during all these
decades, we have listened to complaint after complaint from
consumers and physicians about lack of timely access to
adequate networks for those in Medi-Cal. Today over 70
percent of Californians on Medi-Cal are in managed care and
that proportion is still rising as numerous managed care
transitions continue. About half the consumers that DMHC is
responsible for protecting are in Medi-Cal managed care-yet
there is no focused scrutiny on Medi-Cal managed care plans.
Covered California has been an active purchaser, driving
hard bargains with its contracting plans. Health Access does
not oppose narrow networks but does oppose inadequate
networks that do not assure timely access to medically
necessary care. The National Health Law Program among other
provisions supports that this bill will hold Medi-Cal County
Organized Health Systems to the same standards as other
plans. The March of Dimes indicates that Medi-Cal pays for
nearly 50 percent of births and 1.4 million individuals have
enrolled in an exchange plan so any quality improvements for
both of these types of plans can lead to healthier
pregnancies and healthier babies for a large population.
The California Pan-Ethnic Health Network indicates narrow
networks must be adequate networks that provide timely
access to care so that Californians with coverage through
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Covered California get the care they need when they need it.
Western Center on Law and Poverty believes it is critical
with these increases in Medi-Cal managed care that there is
proper scrutiny paid to timely access to care, network
adequacy, continuity of care and quality of care. Western
Center also writes that joint oversight and responsibility
of DMHC and DHCS should be formalized as does this bill.
Western Center indicates that a survey of a plan's
commercial product is not sufficient to give information
about the adequacy of the plan in serving their Medi-Cal or
Covered California enrollees. The California Chapter of the
American College of Emergency Physicians believes Medi-Cal
enrollees are over represented in emergency departments
because they can't get in to see a doctor.
10.Concerns. The Local Health Plans of California (LHPC) is
unclear how this bill better coordinates or streamlines the
existing audit processes between DHCS and DMHC. LHPC is
aware of existing IAs to conduct joint surveys whenever
possible but is also subject to separate audits and ad-hoc
reports that are not coordinated. LHPC is most concerned
that this bill will actually create an additional layer of
audit to ensure the other audits have been conducted. LHPC
is not sure what recent amendments to coordinate surveys
will accomplish since coordination already occurs. LHPC
describes examples of three different plans being audited 16
or 17 times over a three to four year period by different
federal and state agencies. LHPC also believes it is
unnecessary to require a county contracting with DHCS for
Medi-Cal to comply with timely access requirements because
model contract language already requires it.
11.Opposition. The California Association of Health Plans
(CAHP) writes that health plans are held strictly
accountable for enrollee access through regulation, statute,
and contracts with state entities like Covered California
and Medi-Cal. Currently, in order to obtain a license in
California, a health plan must undergo an exhaustive
application process through DMHC, which can take upwards of
a year and entails hundreds of application exhibits
demonstrating every aspect of proposed operations. Plans
must file their entire provider network, GeoAccess standards
and maps (plotting the location of all providers and all
members in each plan region), and methodologies for ensuring
timely access to care. If a health plan desires to expand
into a new line of business, the health plan must file all
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new exhibits demonstrating network adequacy. Once licensed,
health plans must file several weekly, monthly, quarterly or
annual reports and a combination of network, timely access,
and geographic access related reports as a routine part of
health plan operations. Additional ad hoc reports are
routinely requested by DMHC, DHCS, or Covered California.
All health plans already undergo a routine medical survey
within the first year of licensure and every three to five
years thereafter. It is important to note that health plans
pay an annual assessment to the DMHC to support many of
these regulatory functions including a hotline that helps
enrollees if they experience any difficulties accessing
care. CAHP believes this bill will lead to more cost and
administrative burdens.
12.Policy Questions.
a. Application to CDI. The primary focus of
this bill is Medi-Cal managed care plans and plans
participating in Covered California, which at
present are mostly entities licensed primarily by
DMHC. However, County Organizations Health Systems
are not licensed by either department, with the
exception of one, San Mateo Health Plan. One
Covered California carrier is regulated by CDI.
Should some of this bill's provisions be extended to
CDI? For example, should CDI develop a standard
methodology for monitoring timely access, and should
insurers be required to use it?
SUPPORT AND OPPOSITION :
Support: Health Access California (sponsor)
American Federation of State, County and Municipal
Employees AFL-CIO
California Chapter of the American College of
Emergency Physicians
California Coverage and Health Initiatives
California Medical Association
California Pan-Ethnic Health Network
California Primary Care Association
Children Now
Children's Defense Fund - California
March of Dimes California Chapter
National Health Law Program
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PICO California
Service Employees International Union - California
State Council
The Children's Partnership
United Ways of California
Western Center on Law and Poverty
Oppose: California Association of Health Plans
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