DMHC Fines Health Net Health Plan for Failing to Accurately Pay $1.2 Million in Provider Claims
The DMHC took enforcement action against Health Net of California, Inc. (Health Net) including a $225,000 fine for failing to properly reimburse thousands of claims to the plan’s providers. Through a routine financial examination, the DMHC found the plan failed to accurately reimburse a portion of its claims including interest and penalties. The plan has agreed to pay the fine, take corrective actions and remediated 34,433 claims totaling $1.2 million in payments to providers.
The Provider Complaint page on the DMHC website provides more information on how to file a provider complaint with the Department.
RFP No. 22MC-SA013 – Health Equity and Quality Data Analysis (Notice of Intent to Award)
The Department of Managed Health Care (DMHC) solicited bids from qualified entities to provide Health Equity and Data Analysis services.
DMHC Notice of Intent to Award
RFP No. 22MC-SA017 – Gender Affirming Care Quality Standard and Training Curriculum Development (Notice of Intent to Award)
The Department of Managed Health Care (DMHC) solicited bids from qualified entities to provide consultation services to the DMHC for the purposes of convening and facilitating a working group of representatives charged with developing a quality standard for patient experience to measure cultural competency related to the transgender, gender diverse, or intersex (TGI) community and recommending a training curriculum to provide trans-inclusive health care.
DMHC Notice of Intent to Award
DMHC Fines L.A. Care Health Plan $300,000 for Deceptive Enrollment Tactics
The DMHC took enforcement action against Local Initiative Health Authority for Los Angeles County (L.A. Care Health Plan) for misleading 21 of the plan’s enrollees during the enrollment process. The plan has agreed to pay the fine and implement corrective actions, including monthly monitoring of sales staff to ensure misconduct does not recur in the future.
The DMHC encourages health plan enrollees experiencing issues with their health plan, including enrollment and coverage concerns, to file a grievance or appeal with their health plan. If the enrollee does not agree with their health plan's response or the plan takes more than 30 days to fix the problem for non-urgent issues, the DMHC Help Center can work with the enrollee and health plan to resolve the issue. The health plan enrollee can file a complaint or apply for an Independent Medical Review (IMR) with the DMHC Help Center at www.HealthHelp.ca.gov or 1-888-466-2219. If a health plan enrollee is experiencing an urgent issue, they should contact the DMHC Help Center immediately. Help on urgent matters is available 24 hours a day, seven days a week.
Health Plans Must Assist Enrollees Impacted by Natural Disasters
The Department of Managed Health Care (DMHC) requires California health plans to help victims of natural disasters, including earthquakes, wildfires and flooding, who are experiencing problems obtaining health care services. This could include speeding up approvals for care, replacing lost prescriptions and ID cards, or quickly arranging health care at other facilities if a hospital or doctor’s office is not available due to the disaster. The DMHC Natural Disaster Fact Sheet is available in English and Spanish. Health plan enrollees should first contact their health plans, but if they have problems obtaining services or assistance from a plan, they can also contact the DMHC’s Help Center at 1-888-466-2219 or online at www.HealthHelp.ca.gov.
Helpful information and resources can also be found in the California Health and Human Services Agency (CalHHS) Emergency Resource Guide to help prepare for and get help for natural disaster emergencies.
DMHC Report Shows Prescription Drug Costs Increased by $2.1 Billion Over Five Years
The Department of Managed Health Care (DMHC) released the Prescription Drug Cost Transparency Report for Measurement Year 2021. The report looks at the impact of the cost of prescription drugs on health plan premiums and compares this data over five reporting years, 2017 through 2021. Among other findings, the report reveals that health plan spending on prescription drugs increased by $2.1 billion since 2017, including an increase of almost $700 million in 2021.
DMHC Adopts Health Equity and Quality Measures for Health Plans
The Department of Managed Health Care (DMHC) adopted standard health equity and quality measures for health plans with the goal of ensuring the equitable delivery of high-quality health care services for all enrollees. Assembly Bill (AB) 133 (2021) required the DMHC to adopt standard health equity and quality measures that health plans will report on annually to the Department. To identify the measures, the Department convened a Health Equity and Quality Committee of diverse experts including representatives of consumers, health plans, providers, government agencies and research entities. The Committee held several public meetings during 2022, and made recommendations to the DMHC Director on the standard health equity and quality measures.
DMHC-Regulated Health Plans Must Provide Access to Emergency & Urgent Care Abortion Services Out-of-State
As other states have created obstacles and restricted access to reproductive health care, the DMHC issued guidance reminding health plans regulated by the Department of requirements to cover and provide access to emergency and urgent care services when enrollees are out of state. This includes when an enrollee needs emergency or urgent care while in another state that may restrict access to reproductive health care services, like abortion care.
California health plans must provide timely access to medically necessary basic health care services to enrollees, even when those enrollees happen to be outside of California when they need the services. This includes covering out-of-area emergency care and urgently needed care for 23.5 million enrollees in DMHC-licensed commercial and Medi-Cal plans.