The Knox-Keene Act requires health plans to maintain provider networks that are sufficient to ensure that all covered health care services are readily available to each enrollee consistent with good professional practice. In addition, health plans are required to monitor and maintain networks sufficient to provide enrollees access to covered health care services within specific appointment wait time standards and to meet network adequacy requirements set forth within the Knox-Keene Act. To demonstrate compliance with these requirements, health plans are required to annually submit certain information to the DMHC.
On May 1 of each year, reporting plans (full-service health plans and specialized plans that provide mental health services) are required to report to the DMHC information regarding the plan's compliance with timely access standards and with network adequacy requirements, as described in Health and Safety Code sections 1367.03 and 1367.035, and title 28 of the California Code of Regulations, section 1300.67.2.2, subsection (h). In addition, health plans are required to submit data related to out-of-network payments made at contracted facilities, pursuant to Health and Safety Code section 1371.31 subsection (a)(4), and data pertaining to third-party corporate telehealth providers, pursuant to Health and Safety Code section 1374.141 subsection (d), as applicable. The DMHC reviews the data submitted annually for compliance with the Knox-Keene Act and the rules contained in title 28 of the California Code of Regulations.
On May 1 of each year, all profile plans (e.g., restricted and limited full-service, subcontracted and specialized mental health, dental, vision, acupuncture, and chiropractic health plans) are required to annually submit to the DMHC network profile information detailing the plan's approved network names, product lines, network service area, and plan-to-plan contracts, pursuant to title 28 of the California Code of Regulations, section 1300.67.2.2, subsection (h).
Timely Access Compliance Reporting Requirements
Health plans are required to annually submit to the DMHC a Timely Access Compliance Report that includes information related to monitoring the health plans' network compliance with timely access standards, including network rates of compliance with the appointment wait time standards during the previous year.
For rates of compliance to be comparable across all health plans, Health and Safety Code section 1367.03, subsection (f)(3) authorizes the DMHC, in consultation with stakeholders, to develop standardized methodologies that are mandatory for use by health plans in measuring compliance with appointment wait time standards. The DMHC's standardized methodology requires health plans to survey network providers to identify the provider's next available urgent and non-urgent appointments. The results of this survey are used to calculate an urgent and non-urgent rate of compliance with the appointment wait time standards for each of the health plan's networks. Beginning in measurement year 2023, health plan networks will be required to demonstrate compliance with the appointment wait time standards by obtaining a 70% urgent care rate of compliance and a 70% non-urgent care rate of compliance for each network under title 28 of the California Code of Regulations, section 1300.67.2.2, subsections (b)(12)(A) and (f). If a health plan network does not meet either of these standards, the health plan will be required to investigate, submit a corrective action plan and may be subject to disciplinary action, pursuant to title 28 of the California Code of Regulations, section 1300.67.2.2., subsections (d), (f)(1)(I), (h)(6)(C) and (i). Further, the DMHC implemented a performance target for measurement year 2023 that requires a health plan that does not obtain 80% or higher rate of compliance for non-urgent non-physician mental health appointments to submit a corrective action to the DMHC.
The DMHC reviews the information health plans annually submit in the Timely Access Compliance Report, makes recommendations for changes to further protect enrollees and posts final findings in the annual Timely Access Report, pursuant to Health and Safety Code section 1367.03, subsection (i).
Health plans may access the current Timely Access Compliance Report Instructions, Methodology, Survey Tools and Reporting Templates in the Resources tab of the Timely Access and Annual Network Reporting Web Portal. All Plan Letters related to the Timely Access Compliance Report are available on the All Plan Letters webpage.
Annual Network Reporting Requirements
Health plans are required to annually submit to the DMHC information confirming the status of each of the plan's networks and enrollment, including a complete list of the plan's in-network providers, hospitals and other facilities, and enrollees within each network. The requirements for the Annual Network Report are set forth in title 28 of the California Code of Regulations, section § 1300.67.2.2, subsection (h). Health plans also must submit a timely access and network adequacy grievance report, an out-of-network payment report and third-party corporate telehealth provider report, as applicable. Health plans are required to report data regarding clinical encounters with non-physician counseling mental health professionals.
The DMHC reviews the information submitted for compliance with network adequacy requirements within the Knox-Keene Act, in accordance with Health and Safety Code sections 1367.03, subsection (f), 1367.035 subsection (d) and supporting regulations. Health and Safety Code section 1367.03, subsection (f)(5) authorizes the DMHC, in consultation with stakeholders, to adopt network adequacy standards concerning the availability of primary care physicians, specialty physicians, hospital care and other health care, so that consumers have timely access to care. The DMHC is continuing to develop standards and methodologies pursuant to this section of the Knox-Keene Act. The standards and methodologies are available within the DMHC’s All Plan Letters, posted in the All Plan Letter section of the DMHC’s public website.
Related Links
Sections 1367.03, 1367.035, 1371.31 and 1374.141 of the California Health and Safety Code
Section 1300.67.2.2 in Title 28 of the California Code of Regulations
List of DMHC Licensed Health Plans