Spring 2025
Message from the Director
May is Mental Health Awareness Month, and it’s an opportunity to remind ourselves that mental health is just as important as physical health. As part of this effort, the Department of Managed Health Care (DMHC) is raising awareness about health care rights related to behavioral health. The DMHC’s Behavioral Health Care Fact Sheet provides guidance on how to access care and what to do if care is delayed or denied. The Department is also raising awareness through social media, and providing information on behavioral health care rights through a social media toolkit. I encourage you to follow the Department’s social media accounts on Facebook, YouTube, X (formerly Twitter) and LinkedIn, and to help us share these important resources with your networks.
In addition to Mental Health Awareness Month, National Women’s Health Week is also during the month of May. I want to remind health plan members that health plans must cover basic health care services such as recommended screenings, preventive care and medically necessary treatment for women’s health issues. Depending on your age, examples of medically necessary care could include breast cancer screenings and mammograms, maternal care, mental health screenings, and treatment for menopause and perimenopause symptoms. Talk to your provider to understand your specific health care needs and the medically necessary services appropriate for you.
Earlier this week, the DMHC submitted an application on behalf of the state to update California’s benchmark plan to the federal Centers for Medicare and Medicaid (CMS). I want to extend my sincerest gratitude to our stakeholders and members of the public who provided public comments, and participated in the process to select the new coverage requirements under the essential health benefits. Selecting a new benchmark plan will set a new standard for commercial health coverage in California.
I encourage health plan members having trouble accessing the health care services they need, including behavioral health care, to contact their health plan. If the member is not satisfied with their plan’s response, or has an urgent issue, they can file a complaint with the DMHC Health Center at www.DMHC.ca.gov or by calling 1-888-466-2219 (TDD: 1-877-688-9891) for help.
As always, thank you for your support and continued interest in the DMHC. It is an honor to be of service.
Sincerely,
Mary Watanabe
Director
Mental Health Awareness Month
Access to necessary health care services continues to be among the DMHC’s highest priorities. California requires health plans to cover medically necessary health care services, including behavioral health care services. This Mental Health Awareness Month the DMHC is raising awareness around health plan members’ health care rights.
The Department is sharing resources and tools to help health plan members understand their rights related to behavioral health care services, including treatment for mental health and substance use disorders.
Health plans are required to provide coverage for medically necessary behavioral health care services, such as sessions with a therapist, inpatient treatment and medications. Members also have the right to timely and geographically accessible care. If an in-network provider is not available, the health plan must arrange for and cover out-of-network services at no additional cost to the member.
The DMHC’s Mental Health Awareness Month Social Media toolkit includes downloadable social media content to educate plan members about their health care rights. The Department’s Know Your Health Care Rights Fact Sheets on Behavioral Health Care and Timely Access to Care are also available in English and Spanish.
National Women’s Health Week
National Women’s Health Week is observed from May 11-17, and is an opportunity to raise awareness about women’s health issues. This year the DMHC is highlighting the importance of caring for your physical, mental, social and emotional health.
The DMHC wants you to know about the basic health care services health plans must cover, including, among other things, preventive services and screenings, such as mammograms, bone density scans, maternal care, mental health screenings, and treatments for women’s health issues like menopause and perimenopause symptoms. Talk to your provider and health plan about the recommended screenings and medically necessary services that are appropriate for you.
It is important to know you have rights, and what you can do if you are denied care. If your provider or health plan denies, delays or changes your request for medical services you have the right to appeal through a complaint or Independent Medical Review (IMR).
The first step in most cases is to file a complaint, sometimes called a grievance or appeal, with your health plan. If you do not agree with your health plan's response, or it takes more than 30 days for non-urgent issues, you can contact the DMHC Help Center. If you have an urgent issue, you can go to the DMHC Help Center, and do not need to file with your health plan first.
For more information about how to file a complaint with the DMHC, or apply for an IMR, please visit the DMHC website at www.DMHC.ca.gov.
Updates to California’s Benchmark Plan, Essential Health Benefits
The DMHC submitted an application to the federal CMS, on behalf of the state, to update California’s benchmark plan. The new benchmark plan would expand coverage requirements for essential health benefits (EHBs) in the individual and small group markets starting in 2027, following CMS approval.
Adopting a new benchmark plan would expand coverage to include services to evaluate, diagnose, and treat infertility including in vitro fertilization (IVF) and artificial insemination, an annual hearing exam and hearing aids, and expanded durable medical equipment (DME) benefits, including coverage for mobility devices such as walkers, manual and power wheelchairs, and scooters, among other new DME coverage.
Expanding covered benefits through the new benchmark plan followed an extensive public process over the last year. The DMHC worked with the Administration, state Legislature and many stakeholders to update California’s benchmark plan, including holding public meetings to share information on expanding the EHBs and the process to update the state’s benchmark plan. These public meetings provided opportunities for the public to comment about the benefits that should be considered for inclusion in the new benchmark plan. In addition to the public meetings, the DMHC issued public notices on California’s work to update the benchmark plan and accepted public comments on the state’s draft benchmark plan summary.
Visit the Department’s website for more information about the benchmark plan.
Kaiser Permanente Non-Routine Survey & Settlement Agreement
The DMHC issued the Department’s Non-Routine Survey of Kaiser Foundation Health Plan, Inc. (Kaiser Permanente) in March. The Department opened a Non-Routine Survey of Kaiser Permanente in 2022 to review the plan’s behavioral health operations in both Northern and Southern California. All of the deficiencies identified through the Non-Routine Survey are being addressed through Kaiser’s Corrective Action Work Plan under a $200 million Settlement Agreement. In this agreement, Kaiser committed to undertaking a systemic overhaul of its behavioral health care delivery system to improve member experience, access to care and quality oversight.
Health plans are required to provide their members with appropriate access to behavioral health care services, and the DMHC will continue to hold Kaiser Permanente accountable to these requirements in the law. If a health plan member is having difficulty accessing care, they should contact their health plan. If they still are not able to get the care they need, or are not satisfied with their health plan’s response, they should contact the DMHC Help Center at www.DMHC.ca.gov, or by phone at 1-888-466-2219.
Timely Access Report for Measurement Year 2023
Providing timely access to health care services is required under the law and is also a health plan’s fundamental duty to its members. The DMHC’s Timely Access Report summarizes provider appointment availability data health plans submitted to the Department. More information is available in the Timely Access Report for Measurement Year 2023.
To promote transparency, the DMHC published Health Plan Timely Access Data on its website through a new interactive data analytics tool for users to explore the timely access data. This feature provides new tools to filter and sort timely access data by health plan, product type, provider type, and appointment type. Data provided includes detailed health plan network level timely access data, such as the network performance against the rate of compliance and average appointment wait times, as well as provider response rates and enrollment by network.
Health plans must provide members with timely access to care, including an appointment within a specific number of days or hours. The DMHC’s Know Your Health Care Rights Fact Sheet on Timely Access to Care provides more information about the requirements health plans must follow for offering appointments for urgent and non-urgent care, as well as for mental health and substance use disorder appointments and related follow-up care.
DMHC Enforcement Actions
The DMHC’s Office of Enforcement takes action against health plans that violate the law. The primary goal of an enforcement action is to protect health plan members and change the health plan’s behavior to comply with the law.
The Department took enforcement actions against Kaiser Permanente, including $819,500 in fines, for failing to timely handle health plan member complaints, also called grievances or appeals. California law requires health plans to acknowledge receipt of a standard grievance within five calendar days and resolve a standard grievance and send a written resolution to the member within 30 calendar days. The DMHC Help Center referred several member complaints to the Department’s Office of Enforcement for further investigation, which found Kaiser Permanente failed to timely handle a total of 61 complaints. This included failure to timely provide the written acknowledgment of the receipt of the grievance within five calendar days in 14 cases, and failure to timely respond to the member’s standard grievance within 30 calendar days of receipt of the grievance in 54 cases.
The DMHC took enforcement action, including a $550,000 fine, against Blue Cross of California Partnership Plan, Inc. for failing to timely implement an Independent Medical Review (IMR) determination, delaying a health plan member’s medically necessary treatment. Californians enrolled in health plans regulated by the DMHC have the right to appeal their health plan's decision by applying for an IMR if their plan denies, changes, or delays their request for medical services. In this case, a health plan member requested an in-home therapy evaluation and in-home therapy services for a medical condition. The plan denied the member’s request, and the member contacted the DMHC Help Center to request an IMR. The independent reviewer determined the in-home evaluation and therapy were medically necessary and overturned the plan’s denial. The plan acknowledged the IMR determination and authorized the in-home evaluation, but it did not include the in-home therapy services in its authorization letter to the health plan member. The member received authorization for in-home therapy 59 days after the IMR decision, making the plan 54 days late.
Health Plans Must Assist Members Impacted by Natural Disasters
The DMHC is reminding Californians that health plans must ensure health plan members impacted by natural disasters, including floods, earthquakes and wildfires, continue to have appropriate access to medically necessary 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. Read the DMHC’s consumer-focused fact sheet in English and Spanish for more information about what health plans are required to do to help health plan members impacted by a natural disaster.
Resources for Health Plan Members Impacted by Wildfires in Southern California
The DMHC published a resource guide to help health plan members impacted by the wildfires in Southern California find information on how their health plan can help them. The guide also provides contact information for health plans operating in Los Angeles and Ventura counties.
For more information and resources from state, local and federal government visit CA.gov/LAfires.
DMHC Social Media Toolkits
The DMHC works to educate and inform health plan members about their rights and health plan requirements through social media outreach. The Department has developed social media toolkits to help raise awareness and inform the public about their health care rights. You can help the Department spread awareness by sharing these resources with your social media audience.
The DMHC currently has three social media toolkits available in both English and Spanish. The new Mental Health Awareness Month toolkit provides information and resources to help health plan members understand their behavioral health care rights.
The Wildfire Resources toolkit provides guidance about health plan obligations to plan members impacted by wildfires. The posts include the DMHC wildfire resource guide as well as information about access to emergency prescription refills and access to out-of-network providers when in-network providers are not available.
Additionally, the Social Media Outreach toolkit promotes awareness about the rights health plan members have in DMHC-regulated plans and provides information about the appeal process if a member is denied care.
Regulations Update
Fertility Preservation
The purpose of this regulation package is to require health plans to cover fertility preservation services when a health plan member has or will undergo a treatment that could result in becoming infertile and follows passage of Senate Bill (SB) 600 (Portantino, 2019). Fertility preservation services include egg or sperm retrieval, embryo creation, gonadal tissue retrieval, and cryopreservation of the genetic material taken from the enrollee. The regulation will, among other things, specify how many retrievals of genetic material a health plan must cover, and how long a health plan must cover storage of genetic material.
On February 27, 2024, the DMHC submitted the rulemaking package to the Office of Administrative Law (OAL) for the public notice of rulemaking action. Three public comment periods were held from March 8, 2024 through April 23, 2024, October 2, 2024 through October 17, 2024, and January 13, 2025 through January 28, 2025. The OAL approved the regulatory package on April 30, 2025, and the regulation will be effective July 1, 2025.
Provider Directories
The purpose of this regulation is to codify and further specify the requirements of SB 137 (Hernandez, 2015) by updating and promulgating the requirements of the Uniform Provider Directory Standards and by enumerating and defining the scope of requirements for a provider directory or directories and the obligations of health plans regarding provider directories.
The DMHC submitted the rulemaking package to OAL for public notice of rulemaking action on December 31, 2024. The Department is reviewing comments submitted during the public comment period that ran from January 10, 2025 through February 24, 2025. The DMHC anticipates initiating a second comment period by June 2025.
DMHC Help Center
The DMHC Help Center protects health plan member rights, resolves member complaints, and helps members navigate and understand their coverage ensuring access to health care services.
The DMHC encourages health plan members experiencing issues with their health plan to first file a complaint, sometimes called a grievance or appeal, with their health plan. Common issues include getting timely access to care, receiving an inappropriate charge or bill, or a denial or delay in care or treatment. If the member does not agree with their health plan's response to their complaint or the plan takes more than 30 days to fix the problem for non-urgent issues, the member can contact the DMHC Help Center. The DMHC Help Center will work with the member and health plan to resolve the issue. The health plan member can file a complaint with the DMHC Help Center at www.DMHC.ca.gov or 1-888-466-2219. If the health plan member has an urgent grievance, they do not need to file with their health plan first. A health plan member with an urgent grievance can file directly with the DMHC Help Center.
If a health plan denies, changes or delays a request for health care treatment or services, denies payment for emergency treatment or refuses to cover experimental or investigational treatment, a health plan member can apply for an Independent Medical Review (IMR) through the DMHC Help Center. Independent providers will review the case, and the health plan must follow the IMR determination. Approximately 72% of health plan members who file an IMR with the DMHC receive their requested treatment or service from their health plan. For more information about the IMR process or to apply for an IMR, please visit www.DMHC.ca.gov.
DMHC Career Opportunities
The DMHC has many exciting career opportunities available and is committed to attracting, hiring, and retaining quality employees who can help fulfill the mission of the Department to protect consumers’ health care rights and ensure a stable health care delivery system. More information about careers with the DMHC is located on the CalCareers website and the DMHC website under career opportunities. We encourage you to see what the DMHC has to offer!
DMHC Web Banners
You can help the DMHC raise awareness about health plan member rights and the DMHC Help Center. The Department created the following web banners to help raise awareness of the DMHC Help Center.
If your organization is interested in hosting the DMHC web banners on your website, please visit the DMHC website or email stakeholder@dmhc.ca.gov. The web banners are also available in additional languages, including Spanish.
About DMHC:
The DMHC protects the health care rights of more than 29.8 million Californians and ensures a stable health care delivery system. The DMHC Help Center has assisted approximately 2.9 million health plan members resolve complaints and issues with their health plan. The DMHC Help Center provides assistance in all languages and all services are free. For more information visit www.DMHC.ca.gov or call 1-888-466-2219.