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.
In order 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).
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 contracted providers, hospitals and enrollees within each network. 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. 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.