It’s Time for Timely Access Patient Protections!

HEALTH ACCESS UPDATE
Wednesday, January 20, 2010

CALIFORNIANS WIN FIRST-IN-NATION CONSUMER PROTECTIONS
SETTING STANDARDS FOR TIMELY ACCESS TO CARE
* CA Department of Managed Health Care Announces New Standards Today in LA
* HMO Patients Can Expect Quick Phone Advice; Urgent Care within 2-3 Days
Routine Appointments within 2-3 Weeks
* Timely Access Rules To Help Prevent Health Problems From Getting Worse;
and Reduce Unneeded Trips to Emergency Rooms

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SACRAMENTO–California consumers will have greater assurance of getting appointments and care when they need them. New first-in-the-nation consumer protections are being put in place this week by the California Department of Managed Health Care. As a result, consumers should get a primary care appointment within 10 days, an appointment with a specialist within 15 days and urgent care much more quickly.

Taking effect January 17th, these new regulations to ensure timely access to care implement a 2002 law (AB2179, authored by Assemblywoman Rebecca Cohn, and sponsored by Health Access California), and respond to common consumer complaints about their inability to get health care advice or appointments within a reasonable amount of time.

These groundbreaking consumer protections will help ensure that HMO patients get the care they need, when they need it. Consumer advocates argued that care delayed is often care denied, leading to worse health outcomes or unnecessary visits to the emergency room. These new first-in-the-nation patient rights will provide consumers with clear expectations about how quickly they should get in to see a doctor or specialist.

The new rules ensure that when managed care consumers agree to a limited network of providers, insurers fulfill their promise that their networks of doctors and specialists have the capacity to take care of their paying patients. While the concept of timely access to health care was one of the cornerstones of the original Knox-Keene Act of 1975 that established and regulated managed care in California, it remained largely unrealized and unenforced.

For the first time, the new consumer protections detail specific time-elapsed standards by which patients can expect to get a telephone questioned answered, an urgent care appointment, or a routine appointment for a primary care doctor or specialist.

Here are some examples of the new Consumer Time Elapsed Standards contained in the regulation:

* Triage or screening by telephone 24-7
* Waiting time for telephone triage no longer than 30 minutes
* During normal business hours, waiting time to speak to a plan’s customer service representative no longer than 10 minutes
* 48 hours for urgent care appointments that do not require prior authorization
* 96 hours for urgent care appointments requiring prior authorization (including specialists)
* 10 business days for non-urgent primary care appointments
* 15 business days for non-urgent appointments with specialists
* 10 business days for non-urgent appointments with a mental health care provider
* 15 business days for non-urgent appointments for ancillary services (x-rays, lab tests, etc.) for diagnosis or treatment of injury, illness, or other health condition

For Dental Plans
* 72 hours for urgent care
* 36 business days for non-urgent care
* 40 business days for preventive care

Consumers who believe they have been denied timely access to care, should promptly complain to their health plan. If that doesn’t resolve the issue, they should file a complaint with the Department of Managed Care (DMHC) at the HMO Help Line at (888) HMO-2219 [(888) 466-2219] or (877) 688-9891 [TDD] or at www.hmohelp.ca.gov

These new first-in-the-nation consumer protections have several benefits for individual patients and for the health system:

* Patients will get some clear standards for how long they should—and should not—wait to see a doctors or specialists. They also have a place to com
* Patients will get better guidance about when and where to get treated, through telephone triage and urgent care appointments within 1-3 days. This may reduce inappropriate use of emergency rooms, where patients face long waits and expensive cost-sharing.
* Emergency room overcrowding may be eased, since the recent increases have been with *insured* patients—who likely could not get in to their doctors in a timely manner.Health outcomes can improve if problems are caught early and before they grow, when there are more and usually less expensive options for treatments.
* New attention to wait times can expose broader issues with a health insurer’s lack of an adequate network of provider, lack of appropriate financial resources to patient care, regional shortages, insufficient accountability or oversight of providers, or financial insolvency.
* In an era of health reform, when people have been scared about talk of waiting lists and rationing, these rules provide reassurance that patients get the care they need, and that the reforms work to reduce, rather than expand, waiting times.

Consumer groups, including Health Access California, Western Center on Law and Poverty, and the California Pan-Ethnic Health Network, were pleased that the Department did not adopt industry proposals to allow health plans to determine their own standards, or to exempt providers offering language interpretation services.

The rules will be officially unveiled at a press conference today at Cedars-Sinai Hospital in Los Angeles. More information, including fact sheets, is available at http://www.health-access.org, and at http://www.dmhc.ca.gov.

Health Access California promotes quality, affordable health care for all Californians.

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