California Health Plans Flunk Timely Access Report

A new report by the Department of Managed Health Care (DMHC) found industry-wide problems providing timely access to care, or even accurately reporting the size and availability of their provider networks. Almost all—36 of 40—of the health plans monitored by the DMHC have been referred to the Department’s enforcement unit for potential fines or corrective action plans.

California law requires health plans to provide timely access to care. This means that there are limits on how long patients have to wait to get health care appointments. For example, patients must get urgent care appointments within 48-96 hours, primary care appointments within 10 business days, and specialist appointments within 15 business days. Health plans must monitor their networks, measure appointment availability and submit compliance reports to the DMHC.

DMHC’s findings suggest that Californians are not getting the access to care they are promised in exchange for their premiums, including getting a needed appointment to see a primary care provider within 10 business days or specialist within 15 business days, if not sooner for more urgent conditions. Since 1975, the Knox-Keene Act has required health plans to make “all services readily available at reasonable times consistent with good professional practice.” More than forty years later, health plans cannot document that they provide timely access to care for consumers—even over a decade after regulations put in place clear appointment wait time standards. In fact, health plans say they have more doctors available to provide care than they have contracts with.

Health plans appear to be shirking their decades-long obligation to provide timely access to care. This new reports finds widespread errors in reporting, if not industrywide noncompliance with a key part of the law, which promises patients can get care when they need it.  These health plans must be held accountable for their obligations to consumers. It is absolutely unacceptable for almost all of the state’s health plans to be disregarding its responsibilities. Patients demand accountability, and health plans should be fined for failing to comply with the law and forced to meet their obligations.

Health Access California was the sponsor of SB 964 (Hernandez) that requires this annual report. DMHC’s report, which was unveiled last week, shows the health plans counted doctors who were not actually in the plan’s network.

  • Five plans said they had 70%-80% more specialists available to provide care than they had contracts with, These included plans like Aetna, and United.
  • For primary care providers, plans reported a third more doctors available to provide care than they had contracts with.
  • Plans in the top four in terms of enrollment also had serious problems, including Anthem and HealthNet for primary care doctors.
  • One plan, Aetna, double-counted a group of cardiologists 160 times.
  • Other plans reported that consumers got timely care more than 100% of the time, something that is literally not possible.

DMHC’s report is the result of new reporting requirements imposed by SB 964 of 2014 by Senator Ed Hernandez, Chair of the Senate Health Committee. Senator Hernandez, himself a health care professional, said about the report “I authored SB 964 to hold health plans accountable for their promises of adequate networks. Their inability to accurately document which providers are in their networks raises serious questions about the reliability of these networks. They must do better, and I expect DMHC to enforce the law so Californians have reliable access to health care.”

This report also adds additional concern about the access provided by two of California’s biggest insurers, Blue Shield (which also owns Care1st), and Anthem. Both insurers have repeatedly been found to have inaccurate provider directories. These health plans are collecting premiums promising access to care that they cannot prove they are actually providing. Especially for repeat offenders like Blue Shield and Anthem, it’s high time for them to prioritize patients and meet the standards that have been in place for years if not decades.

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