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 in the Knox-Keene Act.
By 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 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, sub. (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 sub. (a)(4), and data pertaining to third-party corporate telehealth providers, pursuant to Health and Safety Code section 1374.141 sub. (d), as applicable. The DMHC reviews the data submitted annually for compliance with the Knox-Keene Act and rules contained in title 28 of the California Code of Regulations.
Also by May 1 of each year, profile-only plans (e.g., restricted and limited full-service, subcontracted, 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, enrollment status, and plan-to-plan contracts, pursuant to title 28 of the California Code of Regulations, section 1300.67.2.2, sub. (h).
Timely Access Compliance Reporting Requirements
By May 1 of each year, health plans are required to submit to the DMHC a Timely Access Compliance Report that includes information related to compliance with timely access standards. This Report includes survey results indicating the percentage of a plan's providers with a medical appointment available within certain time frames during the previous year. This is called the health plan's "rate of compliance".
For the rate of compliance to be comparable across all health plans, Health and Safety Code section 1367.03, sub. (f)(3) authorizes the DMHC to work with the public to develop a methodology that health plans must use to measure compliance. This methodology requires health plans to survey network providers to identify the provider's next urgent, non-urgent, and mental health follow-up appointment. This survey includes primary care providers, specialist physicians, psychiatrists, non-physician mental health providers, and ancillary service providers.
A health plan is compliant if it achieves a 70% urgent care rate of compliance, a 70% non-urgent care rate of compliance, and an 80% non-physician mental health follow-up rate of compliance. (See title 28 of the California Code of Regulations, section 1300.67.2.2, sub. (b)(12)(A) and (f)). Compliance is determined for each of a health plan's networks. For each non-compliant network, a health plan is required to investigate the reasons for non-compliance and submit a corrective action plan to the Department. A non-compliant health plan may also be subject to disciplinary action, under title 28 of the California Code of Regulations, section 1300.67.2.2., sub. (d), (f)(1)(I), (h)(6)(C) and (i).
Furthermore, a health plan must submit reliable data. A health plan's data is unreliable if its survey for any network has a greater than 5% sampling error, which is based on whether a health plan surveys a sufficient amount of providers (See title 28 of California Code of Regulations, section 1300.67.2.2, sub. (f)(1)(I)).
The DMHC reviews data submitted by health plans, prepares the annual Timely Access Compliance Report, and posts its findings on the Department's website (See Health and Safety Code section 1367.03, sub. (i)). This report includes recommendations to help consumers make informed decisions on their health care.
Note: Health plans may access 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 health plan's networks and enrollment, including a complete list of the health plan's 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, sub. (h). Health plans also must submit a timely access and network adequacy grievance report, an out-of-network payment report and a third-party corporate telehealth provider report, as applicable. Health plans are also required to report data regarding clinical encounters with non-physician counseling mental health professionals and non-network provider requests. Reporting requirements are set forth in title 28 of the California Code of Regulations, section 1300.67.2.2, sub. (h), and the submission instruction manual and report forms are incorporated within this Rule.
The DMHC reviews the submitted network information for compliance with network adequacy requirements within the Knox-Keene Act, in accordance with Health and Safety Code sections 1367.03, sub. (f), 1367.035 sub. (d) and supporting regulations. Health and Safety Code section 1367.03, sub. (f)(3) authorizes the DMHC, in consultation with stakeholders, to develop and update standardized reporting methodologies for this network adequacy review. This includes updates to title 28 of the California Code of Regulations, section 1300.67.2.2 (h), and incorporated documents. Health plans may access the current Annual Network Report Instructions and Reporting Templates in the Resources tab of the Timely Access and Annual Network Reporting Web Portal. All Plan Letters related to the Annual Network Report submission are available on the DMHC's All Plan Letters webpage.
Health and Safety Code section 1367.03, sub. (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 and update network adequacy requirements, standards and methodologies, pursuant to this section of the Knox-Keene Act. This includes updates to title 28 of the California Code of Regulations, section 1300.67.2, and incorporated documents. Updates to network adequacy requirements, 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. Updates are also available on the Laws and Regulations section of the DMHC’s website, once filed with the Secretary of State.
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
Section 1300.67.2 in Title 28 of the California Code of Regulations
List of DMHC Licensed Health Plans