California became the first state to set limits on how long HMO patients must wait to see a physician when the California Department of Managed Health Care (“DMHC”) adopted certain “timely access” regulations in 2010, based upon a 2002 law.[1] These regulations require health plans to maintain provider networks sufficient to ensure that consumers can get appointments and services, such as interpreter support, within specified timeframes. For example, members must be able to obtain an appointment for a non-urgent primary care provider appointment within 10 business days. Plans are required to monitor their own networks and submit annual reports.
Groups representing California health plans and physicians have maintained that collecting and reporting timely access data is difficult. This difficulty is reflected in each annual report in which the DMHC summarizes its findings and recommendations related to the timely access protections. According to the DMHC, Timely Access Compliance Reports submitted by plans for years 2010 through 2014 were not useful either in determining individual health plan compliance or for comparing plans across the industry due to variation in the techniques or methods used by different health plans when gathering data and measuring compliance. As a result, in 2015, following a change in law, the DMHC created a standard methodology that all health plans are required to follow when gathering data, measuring compliance and submitting annual reports. However, despite the application of such mandatory methodology to year 2015, the DMHC’s most recent Timely Access Report states that the agency is unable to determine whether health plans met the Timely Access requirements as 90% of submitted reports contained one or more significant data inaccuracies.[2]
The DMHC is evidently frustrated by what it believes is a “lack of commitment by California’s health plan industry” to comply with the regulations. The agency states that it will take immediate steps to correct deficiencies and ensure that health plans submit accurate data in all future compliance reports, and that it will refer certain plans to the Office of Enforcement for investigation based upon the 2015 data. At the same time, many physicians and health plans question the connection between wait times and quality of care. They believe healthcare in California has significantly changed in the past 15 years necessitating a fresh look at the underlying statute. That is, however, a debate for another day; Plan reports for year 2016 are due March 31st.
[1] The regulations are codified at 28 CCR 1300.67.2.2.
[2] The complete report, published in February 2017, is available here.