Setting the Standards…

Friday, February 9th, 2006

* Language Access Regulations Approved
* Upcoming Hearing on Timely Access Standards
* Comments Due on Proposal to Review Retroactive Denials of Coverage
* Other Key Issues Under Consideration

After laws are passed, the work has just begun for many health advocates. Agencies, such as the Department of Managed Health Care (DMHC), are charged with writing the implementing regulations (specific rules, provisions, deadlines, and other details) that often fill-in the broad outline of the legislation itself. Organizations on all sides of an issue are active in negotiating the terms and conditions of the law when the agency drafts the regulatory language. As a result, it is important to follow closely laws all of the way through the agency’s regulatory process to assure that its important consumer protections and legal requirements remain intact.

On February 5, 2007, Health Access and other organizations convened a meeting with the Cindy Ehnes, DMHC Director, and her staff to discuss several consumer issues and receive updates on recent regulatory developments with a broad group of consumer advocates. The issues ranged widely, and included: high deductible health plans, discount health cards, mental health services, disability access to care, balance billing, Medicare Part D plan oversight, and other key issues.

In addition to informal give-and-take with DMHC staff on several key consumer initiatives and updates on their regulatory and enforcement actions, the Director agreed to host an ongoing series of conversations with consumer advocacy organizations to seek their input and advise of actions and approaches undertaken by her department.
The following are some highlights and updates from that meeting and recent regulatory activity ongoing at the Department of Managed Health Care (DMHC):

LANGUAGE ACCESS TO CARE: DMHC has completed the regulations implementing SB 853 (Escutia) which took major steps to establish Cultural and Linguistic Access to Care. They will be effective on February 22, 2007. This landmark legislation, originally sponsored by California Pan-Ethnic Health Network, MALDEF, and Western Center on Law and Poverty, requires health plans for the first time to assess the language needs of their members. They must offer translations of important written materials for their members in threshold languages. They must also provide interpreter services in the patient’s primary language when they need care, instead of making low-English proficient patients wait for care or rely on untrained friends or family members, even minor children, to interpret for them. However, advocates were disappointed that in the final version of the regulation DMHC permitted health plans to scale back measures they were required to undertake to inform their members of this new requirement.

ACTION: Advocates should advise their membership and allies of the new requirement to provide linguistic and cultural access to health care. Since health plans are required to do only limited outreach and informing of this new provision, advocacy organizations should widely publicize this new right and exercise it when providing direct services to clients.

TIMELY ACCESS STANDARDS: DMHC has again taken up the issue of Timely Access to Care, to implement a bill sponsored and passed by Health Access in 2002. Advocates have long contended that if patients are not able to get appointments to see health practitioners within reasonable time frames, particularly for urgent or emergency care, it is virtually equivalent to a denial of care. Although this has been a problem for years, it remains the most common complaint that members have with their health plans. It also is a significant contributor to the increased costs for health care because patients who cannot tell if their symptoms are indicative of a serious medical emergency or not, end up going to the emergency room—which is the most expensive entry into the health care system. It is important for health plans to have sufficient providers for their members to receive quick appointments and have a reliable clinical mechanism to determine what is a true emergency or requires urgent care.

ACTION: DMHC is holding a public hearing on Timely Access to Care regulations on March 5, 2007 in Sacramento. Your organization can give oral testimony on this issue at the public hearing and/or provide written comments (due the same day) about how important this issue is to the delivery of health care in California . Details are on their website at

RETROACTIVE DENIALS: DMHC has held a recent informal hearing in Los Angeles on the questionable insurance practice called Post-claims Underwriting. This practice involves aggressive sales of health insurance to consumers, only to rescind the policy once a claim is filed, under the rationale that the patient failed to disclose a “pre-existing condition.” The health plan or insurer typically revokes the health insurance policy and refuses to pay the doctor or hospital for services already rendered. They base this on a very minute review of the application for coverage after it has been approved. They look for misunderstandings of poorly-worded questions, incomplete answers, and honest mistakes, often attributing them to the patient’s deliberate attempt to conceal so-called “serious” health conditions. This has recently gotten considerable publicity in a series in The Los Angeles Times for the devastating impact it can have on both consumers’ health and their personal finances.

ACTION: DMHC has invited public comments by February 16, 2007 regarding this practice and whether they should pursue additional regulatory and/or enforcement actions. Written comments may be forwarded to them via email at

FOR MORE INFORMATION: If you have questions or need more information about these regulatory actions or administrative advocacy with the DMHC or other state agencies involving health policy or enforcement, please contact Elizabeth Abbott at Health Access, at (916) 497-0923, ext. 201 or at

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