Healthcare Litigation

By Sarah E. Gettings

Standardizing Health Plan Reporting on Access to Care

Regulators in many states are requiring greater standardization of reporting and transparency of data concerning provider networks and access to care. The increased standardization and transparency means more meaningful plan-to-plan comparisons, including between Affordable Care Act (ACA) and non-ACA plans, will soon be possible. The focus on standardization and transparency is driven, in large part, by an increased demand for low-cost healthcare services due to new consumers entering the market under the ACA. Given plans' increasing use of cost-saving strategies such as tailored networks, regulators are struggling to ensure consumers have adequate access to care.

Plan-to-plan comparisons using access-to-care metrics will undoubtedly impact consumers' choices in the marketplace. Health plans should closely monitor their regulators' efforts and examine which metrics regulators consider most important as indicators of access.

In California, the Department of Managed Health Care (DMHC) is well on its way to standardizing timely access reporting in response to recent state legislation enacted to address concerns about ACA health plans.

Case Study: SB 964 in California

California's DMHC has been working over the past year to implement SB 964, a bill that increases oversight over healthcare service plans in an effort to improve plans' compliance with timely access and provider network adequacy standards. The bill was enacted in late 2014.

SB 964's purpose was to address worries over provider networks for Medi-Cal plans and plans sold over the state's health insurance exchange, Covered California. In particular, the bill's sponsors pointed to media reports of lack of access for Covered California enrollees, and enrollees' confusion over networks and benefit design. The broadly worded bill, however, impacts various lines of business and has already impacted plans' timely access reporting, notwithstanding its focus on Medi-Cal and Covered California.

California's Timely Access Regulations

Prior to SB 964's enactment, California's accessibility reporting requirements were not standardized, leading some observers to criticize their effectiveness.

California's timely access regulations are relatively new. In 2010, the DMHC adopted Rule 1300.67.2.2, which requires health plans to design and implement monitoring systems to measure the accessibility and availability of contracted providers.1 It requires plans to have written quality assurance systems and procedures in place to ensure their provider networks are sufficient and that enrollees have timely access to covered healthcare services.2 Under Rule 1300.67.2.2, timely access is not defined based on clinical outcomes. Rather, access is determined by reference to time-elapse standards such as appointment wait times.

Importantly, Rule 1300.67.2.2 does not mandate any particular methodology or procedure for reporting compliance with these timely access standards. As a result, health plans have used different metrics and different approaches over the last few years, making plan-to-plan comparisons nearly impossible.

DMHC Director Shelley Rouillard has reported that measuring timely access has been challenging without standardized reporting.3 During a public presentation earlier this year, Ms. Rouillard said the DMHC has been working closely with health plans since 2010 to tweak the reporting mechanisms so the department can compare how plans perform against each other.4 According to Ms. Rouillard, it has been a "slow process" to determine how best to standardize reporting.

SB 964 Requires Standardization

SB 964 formalizes the standardization process by specifying the data health plans must disclose in annual reports on network adequacy and by requiring the development of standardized reporting on timely access. Also, it makes standardization a priority. Under the bill, DMHC has five years to adopt a standardized reporting methodology for timely access.

During the debate on SB 964, Covered California was a strenuous proponent of standardization, recommending that regulators require health plans to use a common template, common analytics, and coordinated product and network filings with cross-plan comparisons.5 The DMHC is now coordinating with Covered California, so health plans can use the same network templates for their timely access filing and Covered California quarterly network reporting.6

In the short term, the bill created a glut of new work for the DMHC.7 In the long term, however, standardization may streamline its reviews. The DMHC has already adopted two standardized methodologies under SB 964 and is actively working to improve its reporting process.8

The DMHC's reporting methodologies will certainly change over the next few years as the regulator works out the kinks. But plans' compliance with timely access standards will eventually be made publicly available on the Office of Patient Advocate's annual report cards.9 Many dispute whether California's timely access standards are an accurate or useful measure of access to care in the first place, but plans may soon find consumers comparing products based on these standards.


The move toward standardization of health plan reporting means that plan-to-plan comparisons are becoming possible. Health plans would be wise to consider access to care reporting not only as a regulatory issue but also as a marketing concern. Depending on disclosure requirements, plan-to-plan comparisons based on access-to-care metrics could serve as a significant competitive advantage (or disadvantage) in the health insurance marketplace.

1Cal. Code Regs. § 1300.67.2.2(c)-(d).


3Presentation by DMHC Director, Shelley Rouillard, at UCLA Health Forum (Jan. 28, 2015) ("Jan. 28, 2015 Rouillard Presentation") ("Measuring timely access is really really challenging, as anyone here will attest to. When the regulation was passed, there wasn't a set methodology that the department told the plans—you need to do this. And over the last few years, we've been working with the plans and trying to tweak the requirements for reporting compliance, but it's been a slow process. And without a standardized methodology, we can't really compare how plans perform against each other, and that was one of the goals of having a timely access law to begin with.")


5California Legislative Information, SB-964 Health care coverage (2013-2014), available at

6Department of Managed Health Care, Timely Access Network Reporting General Instructions, available at

7Jan. 28, 2015 Rouillard Presentation (explaining that under SB 964, the DMHC must review networks by plan, by product line, by county—which amounts to a total of over 3,000 network reviews in 2015 alone).

8Department of Managed Health Care, Submit Health Plan Filings and Reporting, available at

9Jan. 28, 2015 Rouillard Presentation ("Eventually, the plans' compliance with timely access will appear on the annual report card that the Office of the Patient Advocate puts out each year.").



pursuant to New York DR 2-101(f)

© 2020 Manatt, Phelps & Phillips, LLP.

All rights reserved