On November 4 and 7, 2022, the California Department of Managed Health Care (DMHC) issued two All Plan Letters (APL 22-026 and APL 22-027) concerning compliance with the state’s network adequacy and timely access requirements, including new statutory and regulatory amendments enacted in October 2021 and January 2022, respectively.1
As amended, the rules, among other things:
- Require plans to have enough contracted providers to ensure members receive timely access to care;
- Require plans with tiered networks to meet requirements at the lowest cost-sharing tier;
- Emphasize that timely access standards apply to mental health and substance use disorder providers;
- Require nonurgent follow-up appointments with nonphysician mental health or substance use disorder providers to be offered within 10 business days of prior appointments for members undergoing an ongoing course of treatment;
- Require plans to arrange coverage for out-of-network mental health and substance use disorder care if network coverage is not timely available or is unavailable in the geographic area; and
- Give the DMHC authority to adopt standardized reporting methodologies for plans to demonstrate compliance with timely access and network adequacy standards.
The statutory amendments, in part, codified existing DMHC timely access regulations.
APL 22-026 is to be read in conjunction with APL 22-007, issued earlier this year, in which the DMHC described an overview of changes to monitoring, reporting and submission timing imposed by the new rules. For example, plans must submit a profile with network information (a network access profile), submit data regarding patient encounters with nonphysician mental health professionals, and report providers that are accepting new patients, among other requirements detailed in the letter. Some changes must be implemented in the 2023 reporting year, others as of 2024.
APL 22-026 directs plans to the “Downloads” page of the DMHC filing portal for specific implementation forms and checklists that plans must submit to demonstrate compliance. These forms include a verification attesting to the adoption of all new requirements and a filing grid requiring plans to demonstrate where within a relevant exhibit each new requirement is addressed.
APL 22-027 addresses out-of-area emergency and urgent care services. It reminds health plans that they must provide timely access to medically necessary emergency and urgent care services even if enrollees are outside of the coverage area when care is needed.2 If required care cannot be provided at the member’s location, plans must cover travel, including travel to another state. The APL provides two examples of circumstances when travel must be covered. Plans may need to pay for travel if a member has an accident at a remote location where trauma care is unavailable. Plans may also need to cover out-of-state travel if a member needs abortion services while in a state with a total or nearly total ban. The APL reminds plans that abortion is a “basic health care service” under California law.
These APLs are just the latest move in California’s continued regulatory focus on access to care, and to mental health care in particular. Stakeholders should expect more moves in the near future.
1 Amendments to the Timely Access and Network Reporting statutes and regulations were made in Health and Safety Code Sections 1367.03, 1367.031, 1374.14, 1367.141, and California Code of Regulations, Title 28, Section 1300.67.2.2.
2 An emergency medical condition is defined as a “medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably” place the enrollee’s health in serious jeopardy, seriously impair the enrollee’s bodily functions, or cause serious dysfunction of any bodily organ or part. Cal. Health & Saf. Code § 1317. Section 1300.67(g)(2) defines “urgently needed services” as “those services necessary to prevent serious deterioration of the health of an enrollee, resulting from unforeseen illness, injury, or complication of an existing condition, including pregnancy, for which treatment cannot be delayed until the enrollee returns to the plan’s service area.” Urgent services include “maternity services necessary to prevent the serious deterioration of the health of the enrollee or the enrollee’s fetus, based on the enrollee’s reasonable belief that she has a pregnancy-related condition for which treatment cannot be delayed until the enrollee returns to the plan’s service area.”