One of the most far-reaching and consumer-friendly health care bills enacted this year by Governor Jerry Brown was SB 964 by Senate Health Committee chairman Dr. Ed Hernandez, and sponsored by Health Access California.
Addressing two pressing issues for consumers, network adequacy and timely access to health care, SB 964 was a natural progression of decades of policy work going back to 1975 when then Governor Jerry Brown signed the Knox-Keene Act to assure that consumers in managed care receive the care they need when they need it, at in-network cost sharing. Over the decades since additional consumer protections have been put in place to make meaningful the bedrock principle for managed care: patients accept limited networks and the health plans in return guarantee that the network is adequate enough to provide timely access to care, including primary care in their geographic region, and access to medically necessary care at in-network cost sharing.
Over seven million Californians are or will be enrolled in Medi-Cal managed care: almost 3 million of them will be new to Medi-Cal managed care, either as a result of transitions from fee-for-service and Healthy Families or due to the ACA changes. This is more than a quarter of the population of California. At a time when we are shifting an unprecedented number of people into Medi-Cal managed care plans and with the consumer concerns about the “narrow networks” in Covered California plans, it becomes even more important that we fulfill the promise of the law and ensure that consumers can get the care they need, when they need it.
SB 964 builds on decades of policy work around consumer protections, and the work of the Department of Managed Health Care (DMHC), by enforcing the timely access and network adequacy standards in law and assuring that consumers have timely access to necessary care.
When the Knox-Keene Act was first implemented, DMHC’s predecessor) reviewed network adequacy whenever a health plan was initially licensed or moved into a new area (for instance, when Kaiser Permanente opened a new facility in Bakersfield) or whenever there were sufficient complaints to raise an alarm. In 1975, this probably seemed sufficient. However, this meant that there were health plans that had been operating for decades without a careful look at whether the networks were adequate and care was provided in a timely manner. .
The timely access statute adopted in 2003 required annual review of timely access compliance. Unfortunately, the prior Administration bungled the compliance procedures for timely access, allowing different health plans to use different metrics and approaches for determining compliance and thus making enforcement quite difficult. Under the current Brown administration the DMHC has taken a number of steps to encourage more standardized reporting on timely access and to improve the information collected on network adequacy.
SB 964 standardizes the data to be annually reported by health plans regarding network adequacy and allows the further development of standardized annual reporting on timely access.
Medi-Cal Managed Care
A fundamental promise of Medi-Cal managed care is that Medi-Cal managed care enrollees will receive the same consumer protections as other Californians enrolled in managed care.
SB964 takes a number of steps to assure that consumers in Medi-Cal managed care have the same protections as other Californians in managed care:
- It requires that if a health plan uses a different network for Medi-Cal managed care than for other lines of business, the annual review for timely access and network adequacy be done separately for the separate Medi-Cal network.
- It repeals the existing exemption of Medi-Cal managed care plans from medical surveys done every three years, building on the Brown Administration’s current practice.
- It requires health plans to submit to DMHC the same information on networks and network changes that is already submitted to DHCS so that the departments may check for inconsistencies.
- In the only provisions affecting DHCS, it requires DHCS to post on its website completed medical audits. DMHC already posts completed medical surveys: DHCS does not. This furthers transparency for Medi-Cal managed care plans.
Covered California and the Individual Market
California has led the way in implementing the Affordable Care Act. Not only have the number of uninsured been cut in half, the rate of increase in premiums in the individual market has also been cut in half. In driving down the increase in premiums in the individual market, health plans have made numerous changes, including shifting to narrow networks. The Department of Managed Health Care will soon release two targeted investigations arising out of these changes in the market for coverage sold directly to individuals, inside and outside Covered California.
SB964 takes a critical step to assure that in future years, networks in the individual market are adequate by requiring that if a health plan uses a different network for the individual market than for the small employer market, then the annual reporting on timely access and network adequacy shall be done separately for the different networks.
SB 964 will help people like Charlie who recently was unable to get routine medical care for more than six months:
Though Charlie has an Obamacare Platinum Plan, he was unable to get routine medical care for more than six months. “I chose the Platinum level “Premier Direct Access” plan offered by Anthem Blue Cross Plan,” says Charlie, “because my Sutter primary care doctor was in that network.” “But before I could get in for an initial appointment, Anthem cancelled their contract without notice, leaving me with $640 of not covered expenses!”
“At the same time I had to postpone a scheduled colonoscopy, I also continue to be unable to schedule a required sleep study for potential apnea, which my brother has and which led to a coronary event for him. And Anthem will not even say if my requested provider is In Network or not.”
SB964: Adequate Networks and Timely Access to Managed Care
Almost twenty million Californians rely on coverage regulated by the Department of Managed Health Care. Stories from consumers like Charlie and recent enforcement actions and investigations by the DMHC indicate a need to further strengthen enforcement and oversight of timely access and network adequacy.
For these reasons, we are pleased that Governor Brown has signed SB 964 into law. and Health Access and other consumer advocates are already working with DMHC to begin implementing the new law. The bill takes effect on January 1.VIEW THE FILE Uncategorized