By Taylor C. Brewer

In January 2020, the Department of Managed Health Care (DMHC) published its Timely Access Report for 2018. The Timely Access Regulation, section 1300.67.2.2, Title 28, of the California Code of Regulations (CCR), which became effective in 2010, requires that health plan networks be sufficient to meet a set of standards, which include specific timeframes under which enrollees must be able to obtain care. These standards include wait times to access urgent and non-urgent care appointments and availability of telephone triage or screening services during and after regular business hours. The regulation requires health plans to submit annual compliance reports to the DMHC, which then summarizes this data into the Timely Access Report.

Key Findings for Full Service Health Plans. The Report provides the data each health care plan reported, including graphs displaying the percentage of surveyed providers that meet the wait time standards set forth in section 1300.67.2.2(c). These standards state the time from the initial request for health care services by an enrollee or the enrollee’s treating provider to the earliest date offered for the appointment is no longer than fifteen business days, or in cases involving urgent care is within 48 hours of the request for appointment (see 28 CCR § 1300.67.2.2(c)). The Report further delineated the data, separating information by product survey results (Commercial, Individual/Family and Medi-Cal) and then all provider types (primary care, specialty, non-physician mental health, and ancillary).

Consistently Sharp Health Plan, Kaiser Permanente, and Kern Health Systems ranked among the top three health plans in compliance with the appointment wait time standards. The top plans reported eighty to ninety percent of their providers in compliance.  Consistently, the lowest-performing plans were Central California Alliance for Health and Community Care Health Plan, Inc., reporting in the high sixties and low seventies for both urgent and non-urgent compliant providers. Larger providers like Aetna Health of California, Blue Shield of California, and Anthem Blue Cross all remain generally towards the median reporting within the high seventies and low eighties. [See Report at 12 (Chart 1)]

Notably, providers’ lowest compliance occurs among providers who are expected to meet the urgent appointment wait time standards. [See Report at 20 (Chart 9)]

Behavioral Health Plans. Of the six reporting behavioral health plans, Managed Health Network held the highest compliance percentage at 80 percent. OptumHealth Behavioral Solution of California was the lowest at 73 percent. For non-urgent appointments, this percentage increased as the plans reported compliance ranged from a high of 90 percent to a low of 82 percent. [See Report at 29 (Chart 17)]

Conclusions and Next Steps. According to the report’s conclusions, the Department plans to improve the accuracy and completeness of the yearly timely access compliance data. Health plans are obligated to follow the mandatory methodology under the CCR, but it is up to the Department to enforce such compliance and refer those that fail to comply to the DMHC Office of Enforcement (see 28 CCR § 1300.67.2.2(g)).

DMHC also reports that it plans to amend the existing timely access regulation in 2020 to include a rate of compliance standard that will be applied to each health plan network rather than aggregated by health plan. DMHC also hopes to require health plans to continue utilizing an external vendor to perform a quality assurance review and include a validation report of the health plans’ data before submission to the Department. The Department has also committed to review stakeholder input as it begins the formal rulemaking process to amend its timely access regulation.

At this writing, the Department has not yet formally noticed these proposed amendments to the Office of Administrative Law (OAL).