Report: CA Health Plans Still Struggle to Meet Timely Access Standards


new report by California’s Department of Managed Health Care (DMHC) released today is the first of its kind to provide data on timely access to care separating out commercial, individual/family, and Medi-Cal health plans. Health Access sponsored 2014’s SB 964 (Hernandez) that requires this annual report.

The report found industry-wide difficulty providing timely access to care, with no plans providing an appointment within the designated time frame 100% of the time. Very few health plans provided timely access over 90% of the time.

For commercial coverage, 14 out of 22 plans, a clear majority, provided timely access more than 80% of the time but for Medi-Cal managed care a distinct minority of plans, 7 out of 18 plans, provided timely access 80% of the time. For both commercial and individual/family plans, Sutter Health was by far the worse plan, only able to find a timely appointment for a patient 63% of the time, while Valley Health Plan was able to provide an appointment 99% of the time. For Medi-Cal managed care, Santa Clara Family Health Plan was only able to meet the timely access standards 65% of the time, while the Health Plan of San Joaquin was able to meet it 99% of the time.

The DMHC report also looked at the access times for behavioral health plans finding worse results in ensuring that patients are receiving the mental health care they need in a timely manner. Only 2 out of 6 plans provided timely access to care at least 80% of the time. OptumHealth Behvioral Solutions of California was only able to find patients a timely appointment 64% of the time, while Value Behavioral Health of CA was able to do so 83% of the time.

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 most Californians in private plans are not getting the access to care they are promised in exchange for their premiums, and Californians in Medi-Cal are struggling even more to get these timely appointments. 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, both private and public 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.

Patients demand accountability, and health plans should have some consequences for failing to comply with the law and forced to meet these long-established obligations.