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Similar to Barcellona Cshc 2010 Presentation
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Barcellona Cshc 2010 Presentation
- 1. Implementing the DMHC’s Timely Access Regulation Bill Barcellona CSHA Annual Conference Monterey, April 9 2010
- 2. Getting it Done in 2010 Timely Access Reg. Health Care Reform My Daughters’ Braces
- 3. History The HMO backlash resulted from the failure of Managed Care Organizations to build patient trust and deliver satisfaction Several notable business failures permeated the public consciousness “Care delayed is care denied” became a universally accepted perception of HMOs
- 4. Symptoms of a Larger Problem “Specifically the lack of timely access to care often conceals: inadequate provider networks, insufficient financial resources devoted to providing care, insufficient accountability/oversight of providers, contracting imbalances by medical specialty or geographic area, and/or financial insolvency” - Health Access, the Back Story, Abbot, 12/22/09
- 5. AB 2179 Passed in 2002 “This bill is sponsored by Health Access California to ensure that enrollees have access to needed health care services in a timely manner. HAC states that health plans enrollees cannot get care when they need it, resulting in emergency rooms filled with health plan enrollees who cannot get timely appointments with their physician, enrollees waiting for extended periods of time to get through on the telephone to providers and health plans, and enrollees unable to get referrals to specialists in a timely manner.” - Bill analysis prepared by Scott Bain, August 26, 2002
- 6. Do these problems still exist? Not to the same extent and degree: Industry consolidation and shakeout occurred Since 2002, closures/disruptions are very slight SB 260 financial solvency requirements work HMO provider networks are broad/ PPO broader Providers created advanced access programs, patient portals, secure email communications
- 7. Statutory Requirements Both CDI and DMHC required to write regulations adopting standards for timely access to care by 2004 Establish time-elapse, monitoring, compliance and enforcement standards Regulators given the authority to permit alternative standards
- 8. The Regulation Title 28, Section 1300.67.2.2 Timely Access to Non-Emergency Health Care Services
- 9. Organization of the Reg. Application Definitions Standards Quality Assurance Processes Enrollee Disclosure and Education Alternative Standards Filing Implementation and Reporting
- 10. Key Application Provisions Does not cover emergency services, but does cover hospital-based non-emergency services Requirements can be delegated to providers via contract Limited application to specialty health plans
- 11. Key Definitions “Advanced Access” was modified to included same day or next business day “Appointment Waiting Time” was modified to exclude office waiting time “Triage or Screening” was modified to focus on the assessment of a patient’s condition rather than diagnosis
- 12. Key Standards The guiding principle: Plans shall provide or arrange for the provision of covered health care services in a timely manner appropriate for the nature of the enrollee’s condition consistent with good professional practice. Plans shall establish and maintain provider networks, policies, procedures and quality assurance monitoring systems and processes sufficient to ensure compliance with this clinical appropriateness standard.
- 14. Quality Assurance Compliance monitoring systems that include: Tracking and documenting network capacity and availability with respect to the standards set forth in subsection (c); (B) Conducting an annual enrollee experience survey, which shall be conducted in accordance with valid and reliable survey methodology and designed to ascertain compliance with the standards set forth at subsection (c); (C) Conducting an annual provider survey
- 15. Enrollee Disclosure Evidence of Coverage and membership cards: Plans shall disclose in all evidences of coverage the availability of triage or screening services and how to obtain those services. Plans shall disclose annually, in plan newsletters or comparable enrollee communications, the plan’s standards for timely access. The telephone number at which enrollees can access triage and screening services shall be included on enrollee membership cards.
- 16. Alternative Standards A plan may file a material modification for approval of alternatives to time-elapse standards or alternative time-elapse standards Provider shortages Development of evidence-based metrics
- 17. Advanced Access
- 20. Implementation Workgroup Stakeholder work group meets frequently to resolve questions over the implementation of: Provider survey – crafted question Patient survey – determined data is already collected Future issues… I vote for an early lunch!
- 21. The CDI Version The Department of Insurance adopted its version sooner than the DMHC No time-elapse standards Focus on geo-access and provider ratios The two regulations create incompatible standards for doctors who won’t know which regulation to follow
- 22. Implementation by the various stakeholders Physicians Health Plans Hospitals
- 23. Physicians & Provider Groups
- 24. Health Plans
- 25. Specialty Plans
- 26. Hospitals & Ancillaries The 15 business day standard applies to all non-emergent hospital-based ancillary services and also applies to diagnostic providers under contract with plans
- 27. Enforcement I’ve got my eye on you! The focus is on patterns of non-compliance rather than isolated incidents A five-factor analysis that looks at referral patterns, clinical appropriateness and “other factors”
- 28. Final Thoughts CHCF predicts 6 million new covered patients by 2014 from health reform We have 67,000 active practice doctors for 38 million Californians Enrollee, circa 2014
- 29. Thank You Bill Barcellona Vice President, CAPG wbarcellona@capg.org 1215 K Street, Suite 1915 Sacramento, CA 95814 (916) 443-4152
Editor's Notes
- 2010 has been an exciting year and we’ve accomplished much that has been in the works seemingly forever. The timely access regulation took over 8 years to complete. Health care reform took more than 50 years. And finally, after 3 long years of waiting, my daughters’ braces came off on March 24th. Oh, happy day.
- In addition to the background provided in my magazine article, the legislative history as written by consumer advocates at Health Access is informative:In 1997, Health Access California sponsored first-ever legislation to require that HMOs providecare in a timely manner. AB497 (Wildman) would have required that HMOs answer the telephonewithin four minutes, provide a non-urgent appointment within ten business days, an urgentappointment with a primary care physician on the same day, and an urgent appointment with aspecialist within 48 hours.In 2002, Health Access California took a different approach: instead of specifying timely accessstandards in statute, AB2179 directed the Department of Managed Health Care to develop timelyaccess standards. AB2179 stated that the DMHC could adopt standards other than time-elapsedstandards if the Department could demonstrate that other standards for assuring timely access tocare were more appropriate for protecting consumers. Through the long regulatory process thatensued, no entity ever demonstrated that any other standard other than time-elapsed standardswere more appropriate for protecting consumers.In 2002, the Department of Managed Health Care, using the Advisory Committee of experts thatthen advised the Department, held a series of public hearings on timely access. Testimonypresented included testimony by a medical group that had converted to same-day access,working down its backlog. This medical group adopted same-day access with the consumer’sown physician because it found that consumer who saw a doctor other than their own went backto their regular doctor for follow-up, a second step that cost unnecessary time and money for theinsurer, the medical group and consumer.The Department also reviewed the timely access guidelines that HMOs had been filing with theDepartment since 1975 when each HMO was asked to develop its own internal guideline fortimely access. There was considerable uniformity among these guidelines but as best anyonecould determine, very little adherence to them. The regulations now adopted incorporatestandards similar to those the HMOs had voluntarily imposed on themselves but failed to complywith for over 30 years.The Regulatory StruggleHealth Access and our coalition partners (including Western Center on Law and Poverty [WCLP]and the California Pan Ethnic Health Network [CPEHN]) have given testimony at three rounds ofpublic hearings, participated in numerous stakeholder meetings, and represented consumersover lengthy and contentious “negotiations” with plans, providers, and associations over thespecific provisions of the Department’s regulations. These regulations have now been approvedand will become effective January 17, 2010.
- Again, from Health Access: Why Are Timely Access to Care Standards So Important?If consumers do not receive timely access to health care, it can—and does—have seriousimplications for that consumer by delaying needed care, limiting treatment options based on thetiming of the course of treatment, and raising the cost of care because only more expensivealternative remain. In addition when consumers cannot get access to timely care, they often seekcare in the most expensive and inefficient setting, the hospital emergency room.In addition, Health Access believes that when plans and providers have not provided timelyaccess to care in the past, it has often masked other more serious problems that go far beyondone patient. In the most serious cases, consumers cannot get timely access to care because theplan does not have sufficient contracted providers in the service area, nor do they have anadequate mechanism to provide access to additional non-contracted providers. The financialstrains which result in an inadequate network can result in the broader disruption of delivery ofservices and can result in the financial failure of health plans and medical groups. Specifically thelack of timely access to care often conceals:inadequate provider networks,insufficient financial resources devoted to providing care,insufficient accountability/oversight of providers,contracting imbalances by medical specialty or geographic area, and/orfinancial insolvencyHealth Access believes that these time-specific, measurable, common sense regulations will helpachieve better health outcomes for Californians who are enrolled in managed care plans. Webelieve the California regulatory language as the first in the nation will be influential in settingclearer benchmark standards during the national debate on health care reform. We believe thesetimely access standards will lay the foundation for clinical treatment and practice guidelines forpeople who have health insurance, in addition to broadening coverage for people without healthinsurance, and introducing significant insurance market reforms.
- From the final Assembly Floor Analysis:1)States legislative intent to ensure that all enrollees of health care service plans (health plans) and health insurers have timely access to health care. Makes legislative findings that timely access to health care is essential to safe and appropriate health care, and that lack of timely access to health care may be an indicator of other systemic problems such as lack of adequate provider panels, fiscal distress of a health plan or a health care provider, or shifts in the health needs of a covered population. States legislative intent that the DMHC be required to incorporate the standards developed under this paragraph in licensing, survey, enforcement, and other processes intended to protect the consumer. 2)Broadens existing legislative intent language in the Knox-Keene Act (the body of law regulating health plans), which currently states it is the intent and purpose of the Legislature to promote the delivery of health and medical care to include, in addition to the delivery of health and medical care, the quality of health and medical care. 3)Requires health plans to make all services readily available at reasonable times to each enrollee consistent with good professional practice, instead of the requirement in existing law that services be readily available at reasonable times to all enrollees. Modifies an existing requirement that, to the extent feasible, the plan is to make all services readily accessible to all enrollees, by requiring that this provision be consistent with the regulations required to be adopted by DMHC under this bill. 4)Prohibits the obligation of a health plan to comply with a provision of the Knox-Keene Act that establishes requirements for health plans regarding facilities, personnel, equipment, continuity of care and ready referral of patients to other providers, service accessibility and availability, and contracts with subscriber and providers from being waived when the health plan delegates any services that it is required to perform to its medical groups, independent practice associations, or other contracting entities. 5)Requires, by January 1, 2004, the DMHC to develop and adopt regulations to ensure that enrollees have access to needed health care services in a timely manner. Requires DMHC, in developing these regulations, to develop indicators of timeliness of access to care and, in so doing, to consider the following as indicators of timeliness of access to care: a) Waiting times for appointments with physicians, including primary care and specialty physicians; b) Timeliness of care in an episode of illness, including the timeliness of referrals and obtaining other services, if needed; and c) Waiting time to speak to a physician, registered nurse, or other qualified health professional acting within his or her scope of practice who is trained to screen or triage an enrollee who may need care. 6)Requires DMHC, in developing these standards for timeliness of access, to consider the following: a) Clinical appropriateness; b) The nature of the specialty; c) The urgency of care; and, d) The requirements of other provisions of law governing utilization review that may affect timeliness of access. 7)Permits DMHC to adopt standards other than the time elapsed between the time an enrollee seeks health care and obtains care. Requires, if DMHC chooses a standard other than the time elapsed between the time an enrollee first seeks health care and obtains it, DMHC to demonstrate why that standard is more appropriate. AB 2179 Page 3 8)Requires DMHC, in developing these standards, to consider the nature of the plan network. 9)Requires DMHC to review and adopt standards, as needed, concerning the availability of primary care physicians, specialty physicians, hospital care, and other health care, so that consumers have timely access to care. 10)Requires DMHC to consider the nature of physician practices, including individual and group practices as well as the nature of the plan network, various circumstances affecting the delivery of care, including urgent care, care provided on the same day, and requests for specific providers. 11)Permits DMHC, if DMHC finds that health plans and health care providers have difficulty meeting these standards, to make recommendations to the Assembly Committee on Health and the Senate Committee on Insurance. 12)Requires DMHC, in developing standards, to consider requirements under federal law, requirements under other state programs, standards adopted by other states, nationally recognized accrediting organizations, and professional associations, the needs of rural areas, specifically those in which health facilities are more than 30 miles apart, and any requirements imposed by the Department of Health Services on health plans that contract to provide Medi-Cal managed care. 13)Requires DMHC to consult with the Clinical Advisory Panel and seek public input from a wide range of interested parties through the Advisory Committee on Managed Health Care. 14)Requires contracts between health plans and health care providers to assure compliance with the standards developed. 15)Requires these contracts to require reporting by health care providers to health plans and by health plans to the DMHC to ensure compliance with these standards. 16)Requires health plans to report annually to DMHC on compliance with the standards in a manner specified by DMHC, and requires the reported information to allow consumers to compare the performance of plans and their contracting providers in complying with the standards, as well as changes in the compliance of plans with these standards. AB 2179 Page 4 17)Requires DMHC, when evaluating compliance with the standards, to focus more upon patterns of noncompliance rather than isolated episodes of noncompliance. 18)Permits the director to investigate and take enforcement action against plans regarding noncompliance with these requirements. Requires, where substantial harm to an enrollee has occurred as a result of plan noncompliance, the director may, by order, assess administrative penalties subject to appropriate notice of, and the opportunity for, a hearing in accordance with a specified provision of existing law. 19)Permits the health plan to provide to the director, and the director to consider, information regarding the plan's overall compliance with these requirements. Prohibits the administrative penalties from being deemed an exclusive remedy available to the director. 20)Requires the director to periodically evaluate grievances to determine if any audit, investigative, or enforcement actions should be undertaken by DMHC. 21)Permits the director by order, after appropriate notice and opportunity for hearing, to assess administrative penalties if the director determines that a health plan has knowingly committed, or has performed with a frequency that indicates a general business practice, either of the following: a) Repeated failure to act promptly and reasonably to assure timely access to care consistent with the Knox-Keene Act; or, b) Repeated failure to act promptly and reasonably to require contracting providers to assure timely access that the plan is required to perform under the Knox-Keene Act and that have been delegated by the plan to the contracting provider when the obligation of the plan to the enrollee or subscriber is reasonably clear. 22)States the administrative penalties available to the director pursuant to specified provisions are not exclusive, and may be sought and employed in any combination with civil, criminal, and other administrative remedies deemed warranted by the director to enforce the Knox-Keene Act. AB 2179 Page 5 23)Requires DMHC to work with the Office of the Patient Advocate to assure that the quality of care report card incorporates information provided regarding the degree to which health plans and health care providers comply with the requirements for timely access to care. 24)Requires DMHC to report to the Assembly Committee on Health and the Senate Committee on Insurance on March 1, 2003, and on March 1, 2004, regarding the progress toward the implementation of specified provisions of this bill. 25)Requires, every three years, DMHC to review information regarding compliance with the standards developed and to make recommendations for changes that further protect enrollees. 26)Requires the commissioner of DOI, before January 1, 2004, to promulgate regulations to ensure that insureds have the opportunity to access needed health care services in a timely manner. Requires these regulations to meet specified criteria, and requires DOI to consider various factors and requirements. 27)Requires DOI to consult with DMHC concerning regulations developed by DMHC and to seek public input from a wide range of interested parties. 28)Requires health insurers to report annually on complaints received by the insurer regarding timely access to care, requires DOI to review these complaints and any complaints received by DOI regarding timeliness of care and to make this information public. 29)Requires DOI to report to the Assembly Committee on Health and the Senate Committee on Insurance on March 1, 2003, and on March 1, 2004, regarding the progress towards implementation. 30)Requires, every 3 years, the DOI commissioner to review the latest version of the regulations adopted and to determine if the regulations should be updated to further the intent of the DOI-related provisions of this bill. The Senate amendments include numbers #2) through #4) above, apply the provisions of this bill to health insurers, and include additional provisions bill regarding DMHC's regulations.
- The regulation spans 11 pages and is organized into 7 sections:
- (a) Application – the scope of the regulation, its applicability to certain plans andhow the requirements are to be passed along to contracted providers;(b) Definitions – provides several key definitions that guide implementation,including recognition of existing advanced access programs, etc;(c) Standards – sets forth the time elapse and telephone answering standards;(d) Quality Assurance Processes – network adequacy provisions for HMO/PPO;(e) Enrollee Disclosure and Education – explanations to enrollees about theirrights to timely access;(f) Alternative Standards – how plans may file for exceptions where theirproviders utilize advance access, or there are gaps in a provider network due toprovider shortages; and(g) Filing Implementation and Reporting Requirements – how the DMHC willmonitor the timely access of services through plan filings of their providernetworks, complaints, etc.
- (a) Application All health care service plans that provide or arrange for the provision of hospital or physician services, including specialized mental health plans that provide physician or hospital services, or that provide mental health services pursuant to a contract with a full service plan, shall comply with the requirements of this section. Dental, vision, chiropractic, and acupuncture plans shall comply with subsections (c)(1), (3), (4), (7), (9) and (10), and subsections (d)(1) and (g)(1). Dental plans shall also comply with subsection (c)(6). The obligation of a plan to comply with this section shall not be waived when the plan delegates to its medical groups, independent practice associations, or other contracting entities any services or activities that the plan is required to perform. A plan’s implementation of this section shall be consistent with the requirements of the Health Care Providers’ Bill of Rights, and a material change in the obligations of a plan’s contracting providers shall be considered a material change to the provider contract, within the meaning of subsections (b) and (g)(2) of Section 1375.7 of the Act. This section confirms requirements for plans to provide or arrange for the provision of access to health care services in a timely manner, and establishes additional metrics for measuring and monitoring the adequacy of a plan’s contracted provider network to provide enrollees with timely access to needed health care services. This section does not: (A) Establish professional standards of practice for health care providers; (B) Establish requirements for the provision of emergency services; or (C) Create a new cause of action or a new defense to liability for any person.
- (b) Definitions. For purposes of this section, the following definitions apply. “Advanced access” means the provision, by an individual provider, or by the medical group or independent practice association to which an enrollee is assigned, of appointments with a primary care physician, or other qualified primary care provider such as a nurse practitioner or physician’s assistant, within the same or next business day from the time an appointment is requested, and advance scheduling of appointments at a later date if the enrollee prefers not to accept the appointment offered within the same or next business day. “Appointment waiting time” means the time from the initial request for health care services by an enrollee or the enrollee’s treating provider to the earliest date offered for the appointment for services inclusive of time for obtaining authorization from the plan or completing any other condition or requirement of the plan or its contracting providers. “Preventive care” means health care provided for prevention and early detection of disease, illness, injury or other health condition and, in the case of a full service plan includes but is not limited to all of the basic health care services required by subsection (b)(5) of Section 1345 of the Act, and Section 1300.67(f) of Title 28. “Provider group” has the meaning set forth in subsection (g) of Section 1373.65 of the Act. “Triage” or “screening” means the assessment of an enrollee’s health concerns and symptoms via communication, with a physician, registered nurse, or other qualified health professional acting within his or her scope of practice and who is trained to screen or triage an enrollee who may need care, for the purpose of determining the urgency of the enrollee’s need for care. “Triage or screening waiting time” means the time waiting to speak by telephone with a physician, registered nurse, or other qualified health professional acting within his or her scope of practice and who is trained to screen or triage an enrollee who may need care. “Urgent care” means health care for a condition which requires prompt attention, consistent with subsection (h)(2) of Section 1367.01 of the Act.
- All standards flow from this guiding principle in the regulation. The regulation is not intended to supplant the good clinical judgment of physicians. (c) Standards for Timely Access to Care. (1) Plans shall provide or arrange for the provision of covered health care services in a timely manner appropriate for the nature of the enrollee’s condition consistent with good professional practice. Plans shall establish and maintain provider networks, policies, procedures and quality assurance monitoring systems and processes sufficient to ensure compliance with this clinical appropriateness standard. (2) Plans shall ensure that all plan and provider processes necessary to obtain covered health care services, including but not limited to prior authorization processes, are completed in a manner that assures the provision of covered health care services to enrollees in a timely manner appropriate for the enrollee’s condition and in compliance with the requirements of this section. (3) When it is necessary for a provider or an enrollee to reschedule an appointment, the appointment shall be promptly rescheduled in a manner that is appropriate for the enrollee’s health care needs, and ensures continuity of care consistent with good professional practice, and consistent with the objectives of Section 1367.03 of the Act and the requirements of this section. (4) Interpreter services required by Section 1367.04 of the Act and Section 1300.67.04 of Title 28 shall be coordinated with scheduled appointments for health care services in a manner that ensures the provision of interpreter services at the time of the appointment. This subsection does not modify the requirements established in Section 1300.67.04, or approved by the Department pursuant to Section 1300.67.04 for a plan’s language assistance program. (5) In addition to ensuring compliance with the clinical appropriateness standard set forth at subsection (c)(1), each plan shall ensure that its contracted provider network has adequate capacity and availability of licensed health care providers to offer enrollees appointments that meet the following timeframes: (A) Urgent care appointments for services that do not require prior authorization: within 48 hours of the request for appointment, except as provided in (G); (B) Urgent care appointments for services that require prior authorization: within 96 hours of the request for appointment, except as provided in (G); (C) Non-urgent appointments for primary care: within ten business days of the request for appointment, except as provided in (G) and (H); (D) Non-urgent appointments with specialist physicians: within fifteen business days of the request for appointment, except as provided in (G) and (H); (E) Non-urgent appointments with a non-physician mental health care provider: within ten business days of the request for appointment, except as provided in (G) and (H); (F) Non-urgent appointments for ancillary services for the diagnosis or treatment of injury, illness, or other health condition: within fifteen business days of the request for appointment, except as provided in (G) and (H); (G) The applicable waiting time for a particular appointment may be extended if the referring or treating licensed health care provider, or the health professional providing triage or screening services, as applicable, acting within the scope of his or her practice and consistent with professionally recognized standards of practice, has determined and noted in the relevant record that a longer waiting time will not have a detrimental impact on the health of the enrollee; (H) Preventive care services, as defined at subsection (b)(3), and periodic follow up care, including but not limited to, standing referrals to specialists for chronic conditions, periodic office visits to monitor and treat pregnancy, cardiac or mental health conditions, and laboratory and radiological monitoring for recurrence of disease, may be scheduled in advance consistent with professionally recognized standards of practice as determined by the treating licensed health care provider acting within the scope of his or her practice; and (I) A plan may demonstrate compliance with the primary care time-elapsed standards established by this subsection through implementation of standards, processes and systems providing advanced access to primary care appointments, as defined at subsection (b)(1). (6) In addition to ensuring compliance with the clinical appropriateness standard set forth at subsection (c)(1), each dental plan, and each full service plan offering coverage for dental services, shall ensure that contracted dental provider networks have adequate capacity and availability of licensed health care providers to offer enrollees appointments for covered dental services in accordance with the following requirements: (A) Urgent appointments within the dental plan network shall be offered within 72 hours of the time of request for appointment, when consistent with the enrollee's individual needs and as required by professionally recognized standards of dental practice; (B) Non-urgent appointments shall be offered within 36 business days of the request for appointment, except as provided in subsection (c)(6)(C); and (C) Preventive dental care appointments shall be offered within 40 business days of the request for appointment. (7) Plans shall ensure they have sufficient numbers of contracted providers to maintain compliance with the standards established by this section. (A) This section does not modify the requirements regarding provider-to-enrollee ratio or geographic accessibility established by Sections 1300.51, 1300.67.2 or 1300.67.2.1 of Title 28. (B) A plan operating in a service area that has a shortage of one or more types of providers shall ensure timely access to covered health care services as required by this section, including applicable time-elapsed standards, by referring enrollees to, or, in the case of a preferred provider network, by assisting enrollees to locate, available and accessible contracted providers in neighboring service areas consistent with patterns of practice for obtaining health care services in a timely manner appropriate for the enrollee’s health needs. Plans shall arrange for the provision of specialty services from specialists outside the plan’s contracted network if unavailable within the network, when medically necessary for the enrollee’s condition. Enrollee costs for medically necessary referrals to non-network providers shall not exceed applicable co-payments, co-insurance and deductibles. This requirement does not prohibit a plan or its delegated provider group from accommodating an enrollee’s preference to wait for a later appointment from a specific contracted provider. (8) Plans shall provide or arrange for the provision, 24 hours per day, 7 days per week, of triage or screening services by telephone as defined at subsection (b)(5). (A) Plans shall ensure that telephone triage or screening services are provided in a timely manner appropriate for the enrollee’s condition, and that the triage or screening waiting time does not exceed 30 minutes. (B) A plan may provide or arrange for the provision of telephone triage or screening services through one or more of the following means: plan-operated telephone triage or screening services consistent with subsection (b)(5); telephone medical advice services pursuant to Section 1348.8 of the Act; the plan’s contracted primary care and mental health care provider network; or other method that provides triage or screening services consistent with the requirements of this subsection. A plan that arranges for the provision of telephone triage or screening services through contracted primary care and mental health care providers shall require those providers to maintain a procedure for triaging or screening enrollee telephone calls, which, at a minimum, shall include the employment, during and after business hours, of a telephone answering machine and/or an answering service and/or office staff, that will inform the caller: a. Regarding the length of wait for a return call from the provider; and b. How the caller may obtain urgent or emergency care including, when applicable, how to contact another provider who has agreed to be on-call to triage or screen by phone, or if needed, deliver urgent or emergency care. A plan that arranges for the provision of triage or screening services through contracted primary care and mental health care providers who are unable to meet the time-elapsed standards established in paragraph (8)(A) shall also provide or arrange for the provision of plan-contracted or operated triage or screening services, which shall, at a minimum, be made available to enrollees affected by that portion of the plan’s network. 3. Unlicensed staff persons handling enrollee calls may ask questions on behalf of a licensed staff person in order to help ascertain the condition of an enrollee so that the enrollee can be referred to licensed staff. However, under no circumstances shall unlicensed staff persons use the answers to those questions in an attempt to assess, evaluate, advise, or make any decision regarding the condition of an enrollee or determine when an enrollee needs to be seen by a licensed medical professional. (9) Dental, vision, chiropractic, and acupuncture plans shall ensure that contracted providers employ an answering service or a telephone answering machine during non-business hours, which provide instructions regarding how enrollees may obtain urgent or emergency care including, when applicable, how to contact another provider who has agreed to be on-call to triage or screen by phone, or if needed, deliver urgent or emergency care. (10) Plans shall ensure that, during normal business hours, the waiting time for an enrollee to speak by telephone with a plan customer service representative knowledgeable and competent regarding the enrollee’s questions and concerns shall not exceed ten minutes.
- (d) Quality Assurance Processes. Each plan shall have written quality assurance systems, policies and procedures designed to ensure that the plan’s provider network is sufficient to provide accessibility, availability and continuity of covered health care services as required by the Act and this section. In addition to the requirements established by Section 1300.70 of Title 28, a plan’s quality assurance program shall address: (1) Standards for the provision of covered services in a timely manner consistent with the requirements of this section. (2) Compliance monitoring policies and procedures, filed for the Department’s review and approval, designed to accurately measure the accessibility and availability of contracted providers, which shall include: (A) Tracking and documenting network capacity and availability with respect to the standards set forth in subsection (c); (B) Conducting an annual enrollee experience survey, which shall be conducted in accordance with valid and reliable survey methodology and designed to ascertain compliance with the standards set forth at subsection (c); (C) Conducting an annual provider survey, which shall be conducted in accordance with valid and reliable survey methodology and designed to solicit, from physicians and non-physician mental health providers, perspective and concerns regarding compliance with the standards set forth at subsection (c); (D) Reviewing and evaluating, on not less than a quarterly basis, the information available to the plan regarding accessibility, availability and continuity of care, including but not limited to information obtained through enrollee and provider surveys, enrollee grievances and appeals, and triage or screening services; and (E) Verifying the advanced access programs reported by contracted providers, medical groups and independent practice associations to confirm that appointments are scheduled consistent with the definition of advanced access in subsection (b)(1). (F) A plan that provides services through a preferred provider organization network may, for that portion of its network, demonstrate compliance with subsections (d)(2)(A) and (D) by monitoring, on not less than an annual basis: the number of PPO primary care and specialty physicians under contract with the plan in each county of the plan’s service area; enrollee grievances and appeals regarding timely access; and the rates of compliance with the time-elapsed standards established in subsection (c)(5). (3) A plan shall implement prompt investigation and corrective action when compliance monitoring discloses that the plan’s provider network is not sufficient to ensure timely access as required by this section, including but not limited to taking all necessary and appropriate action to identify the cause(s) underlying identified timely access deficiencies and to bring its network into compliance. Plans shall give advance written notice to all contracted providers affected by a corrective action, and shall include: a description of the identified deficiencies, the rationale for the corrective action, and the name and telephone number of the person authorized to respond to provider concerns regarding the plan’s corrective action.
- (e) Enrollee Disclosure and Education (1) Plans shall disclose in all evidences of coverage the availability of triage or screening services and how to obtain those services. Plans shall disclose annually, in plan newsletters or comparable enrollee communications, the plan’s standards for timely access. (2) The telephone number at which enrollees can access triage and screening services shall be included on enrollee membership cards. A plan or its delegated provider group may comply with this requirement through an additional selection in its automated customer service telephone answering system, where applicable, so long as the customer service number is included on the enrollee’s membership card.
- (f) Plans may file, by notice of material modification, a request for the Department’s approval of alternative time-elapsed standards or alternatives to time-elapsed standards. A request for an alternative standard shall include: (1) An explanation of the plan’s clinical and operational reasons for requesting the alternative standard, together with information and documentation, including scientifically valid evidence (based on reliable and verifiable data), demonstrating that the proposed alternative standard is consistent with professionally recognized standards of practice and a description of the expected impact of the alternative standard on clinical outcomes, on access for enrollees, and on contracted health care providers; (2) The burden shall be on the plan to demonstrate and substantiate why a proposed alternative standard is more appropriate than time elapsed standards. Plans that have received approval for an alternative standard shall file, on an annual basis, an amendment requesting approval for continued use of the alternative standard, and providing updated information and documentation to substantiate the continued need for the alternative standard; and (3) In approving or disapproving a plan’s proposed alternative standards the Department may consider all relevant factors, including but not limited to the factors set forth in subsections (d) and (e) of Section 1367.03 of the Act and subsection (c) of Section 1300.67.2.1 of Title 28. (f) Plans may file, by notice of material modification, a request for the Department’s approval of alternative time-elapsed standards or alternatives to time-elapsed standards. A request for an alternative standard shall include: (1) An explanation of the plan’s clinical and operational reasons for requesting the alternative standard, together with information and documentation, including scientifically valid evidence (based on reliable and verifiable data), demonstrating that the proposed alternative standard is consistent with professionally recognized standards of practice and a description of the expected impact of the alternative standard on clinical outcomes, on access for enrollees, and on contracted health care providers; (2) The burden shall be on the plan to demonstrate and substantiate why a proposed alternative standard is more appropriate than time elapsed standards. Plans that have received approval for an alternative standard shall file, on an annual basis, an amendment requesting approval for continued use of the alternative standard, and providing updated information and documentation to substantiate the continued need for the alternative standard; and (3) In approving or disapproving a plan’s proposed alternative standards the Department may consider all relevant factors, including but not limited to the factors set forth in subsections (d) and (e) of Section 1367.03 of the Act and subsection (c) of Section 1300.67.2.1 of Title 28.
- What is Advanced Access?Advanced Access is about reengineering clinic practices so that patients can see a physician or other practitioner at a time and date that is convenient for them. It is not just another scheduling system, but in fact, a comprehensive approach to effective patient care delivery. This is a screen shot of Talbert Medical Group’s patient portal:TMG4METalbert Medical Group provides patients with 24/7 access to medical information in the convenience of your own home through our secure TMG4ME website. TMG4ME enables patients to: Print summaries of your doctor's visits Check specialist referral status Request prescription refills Review immunization records View medical records including lab test results Make, change, or cancel future appointments Send e-mails to a Medical Advice Nurse or Customer Service Representative Give family members, guardians, or caregivers access to their medical records (see TMG4ME FAQ for Proxy Access) Sign up for the free service today by:Visiting our TMG4ME website Speaking with any of our front office staff Emailing Talbert Medical Group directly
- (g) Filing, Implementation and Reporting Requirements. (1) Not later than twelve months after the effective date of this section, plans shall implement the policies, procedures and systems necessary for compliance with the requirements of Section 1367.03 of the Act and this section. Not later than nine months after the effective date of this section, each plan shall file an amendment pursuant to Section 1352 of the Act disclosing how it will achieve compliance with the requirements of this section, which shall include substantiating documentation, including but not limited to, quality assurance policies and procedures, survey forms, subscriber and enrollee disclosures, and amendments to provider contracts. The amendment shall also include documentation sufficient to confirm the plan’s compliance, as of the date of filing, with existing requirements regarding physician-to-enrollee ratios, including but not limited to updated Exhibits I-1 and I-4 to the plan’s license application. If a plan asserts prior Department approval of alternative physician-to-enrollee ratios or an alternative method of demonstrating network adequacy, the filing shall contain confirming documentation. A plan may concurrently request approval of alternative physician-to-enrollee ratios or an alternative method of demonstrating network adequacy by filing a notice of material modification pursuant to section 1300.67.2.1 of Title 28. (2) By March 31, 2012, and by March 31 of each year thereafter, plans shall file with the Department a report, pursuant to subsection (f)(2) of Section 1367.03 of the Act, regarding compliance during the immediately preceding year. The first reporting period shall be the calendar year ending December 31, 2011. The reports shall document the following information: (A) The timely access standards set forth in the plan’s policies and procedures including, as may be applicable, any alternative time-elapsed standards and alternatives to time-elapsed standards for which the plan obtained the Department’s prior approval by Order; (B) The rate of compliance, during the reporting period, with the time elapsed standards set forth in subsection (c)(5), separately reported for each of the plan’s contracted provider groups located in each county of the plan’s service area. A plan may develop data regarding rates of compliance through statistically reliable sampling methodology, including but not limited to provider and enrollee survey processes, or through provider reporting required pursuant to subsection (f)(2) of Section 1367.03 of the Act; (C) Whether the plan identified, during the reporting period, (1) any incidents of noncompliance resulting in substantial harm to an enrollee or (2) any patterns of non-compliance and, if so, a description of the identified non-compliance and the plan’s responsive investigation, determination and corrective action; (D) A list of all provider groups and individual providers utilizing advanced access appointment scheduling; (E) A description of the implementation and use by the plan and its contracting providers of triage, telemedicine, and health information technology to provide timely access to care; (F) The results of the most recent annual enrollee and provider surveys and a comparison with the results of the prior year’s survey, including a discussion of the relative change in survey results; and (G) Information confirming the status of the plan’s provider network and enrollment at the time of the report, which shall include, on a county-by-county basis, in a format approved by the Department: The plan’s enrollment in each product line; and A complete list of the plan’s contracted physicians, hospitals, and other contracted providers, including location, specialty and subspecialty qualifications, California license number and National Provider Identification Number, as applicable. Physician specialty designation shall specify board certification or eligibility consistent with the specialty designations recognized by the American Board of Medical Specialties. The information required by paragraphs (g)(2)(G)(1) and (2) shall be included with the annual report until the Department implements a web-based application that provides for electronic submission via a web portal designated for the collection of plan network data. Upon the Department’s implementation of the designated network data collection web portal, the information required by paragraphs (G) (1) and (2), shall be submitted directly to the web portal.
- The CDI version is referred to as Title 10, Section 2240-2240.5. Since the CDI adopted its version first, the DMHC had no alternative but to consider keyprovisions of its counterpart agency’s regulation while drafting its own version.Accordingly, in the DMHC Updated Informative Digest dated November 3, 2009, theDepartment stated that the geographic access standards adopted by the CDI did notconflict with the existing Knox-Keene standards, and that relative consistency had beenachieved between the two versions.14 But the two regulations incorporate substantiallydifferent standards for PPO patients, based exclusively on whether they belong to a planregulated by the DMHC or the CDI. For the former, time elapse standards apply; for thelater, they do not. Both regulators license PPO plans administered by Anthem Blue Crossand Blue Shield of California, whose combined PPO membership comprises two-thirdsof the State’s total. Providers are certain to find this time elapse standard distinctionextremely confusing and nearly impossible to operationalize, if only because they aresure to encounter difficulty discerning under which regulator – the DMHC or the CDI – aparticular patient’s PPO plan is licensed. (
- The regulation expressly limits delegation of a plan’s regulatory duties. While theunderlying statute, Section 1367.03, requires Knox-Keene licensed health plans to ensurecompliance by their network providers, the delegation of the regulatory obligations mustfirst be negotiated with and accepted by providers.15 This section was specifically addedto provide assurance to the physician community that the Department would confirmapplication of Provider Bill of Rights protections.16 The Department has been explicitabout this issue, and the regulation provides:The obligation of a plan to comply with this section shall not be waived when theplan delegates to its medical groups, independent practice associations, or othercontracting entities any services or activities that the plan is required to perform.A plan’s implementation of this section shall be consistent with the requirementsof the Health Care Providers’ Bill of Rights, and a material change in theobligations of a plan’s contracting providers shall be considered a materialchange to the provider contract, within the meaning of subsections (b) and (g)(2), of Section 1375.7 of the Act.The regulation establishes key requirements for delegated providers. The heart of theDepartment’s timely access regulation is its creation of time-elapse standards, specifically:• (A) Urgent care appointments for services that do not require prior authorization:within 48 hours of the request for appointment, except as provided in (G);• (B) Urgent care appointments for services that require prior authorization: within96 hours of the request for appointment, except as provided in (G);• (C) Non-urgent appointments for primary care: within ten business days of therequest for appointment, except as provided in (G) and (H);• (D) Non-urgent appointments with specialist physicians: within fifteen businessdays of the request for appointment, except as provided in (G) and (H); and• (F) Non-urgent appointments for ancillary services for the diagnosis or treatmentof injury, illness, or other health condition: within fifteen business days of therequest for appointment, except as provided in (G) and (H). 17However, it should be noted that the treating or referring physician has the ability tooverride the time-elapse standards specified in the regulation. The specific provisionstates:The applicable waiting time for a particular appointment may be extended if thereferring or treating licensed health care provider, or the health professionalproviding triage and or screening services, as applicable, acting within the scopeof his or her practice and consistent with professionally recognized standards ofpractice, has determined and noted in the relevant record that a longer waitingtime will not have a detrimental impact on the health of the enrollee.18Moreover, the DMHC has taken great pains to emphasize in the supporting materials tothe regulatory text that a physician’s clinical judgment and expertise shall govern overthe time-elapse standards. The Department’s Final Statement of Reasons, datedNovember 3, 2009, and provides:Further, the time-elapsed standards do not establish an enrollee’s entitlement toservices within a specific time-frame. Rather, they are quality assurancestandards for accessibility, which support and augment the clinical standard.They also serve as objective metrics for assessing the adequacy of a plan’snetwork.19The DMHC also struggled with the issue of routine and periodic preventive careappointments, particularly for diabetes and other chronic conditions. In this regard, thefinal version of the regulation provides the following clarification and exception to thetime-elapse standards:Preventive care services, as defined at subsection (b) (3) and periodic follow upcare, including but not limited to, standing referrals to specialists for chronicconditions, periodic office visits to monitor and treat pregnancy, cardiac ormental health conditions, and laboratory and radiological monitoring forrecurrence of disease, may be scheduled in advance consistent with professionallyrecognized standards of practice as determined by the treating licensed health care provider acting within the scope of his or her practice.20Additionally, the regulation mandates that plans cooperate with provider groups in early2010 to devise reporting and monitoring methods around primary care networks thatprovide advanced access programs. The Department will grant certain exceptions to thetime-elapse standards to plans whose provider networks demonstrate this capability.21Insofar as liability and enforcement is concerned, the Department grappled with validconcerns raised by the California Association of Physician Groups and the CaliforniaMedical Association over the potential for increased liability for physician malpractice ifspecific time-elapse standards were adopted.22 The adopted regulation explicitlyprovides that it does not establish professional standards of practice for health careproviders, and, as well, that it does not create any new or different causes of action.23The Department purposefully sought to avoid the use of the regulation’s new time-elapsestandards as a basis for statutory liability of physicians. As such, health plans retainresponsibility for assuring timely access as a fundamental condition of holding a KnoxKeene license. In negotiating the respective division of responsibilities for these newservice requirements, physicians and physician groups would be prudent to considercarefully the precise language of delegation provisions set forth in their agreements withhealth plans. While some capitated, delegated physician groups may wish to assume therisk of providing all timely access to services in their operating area (including the dutyto provide access to non-contracted physician services when necessary), others may electto contract only for access to their own physician network. This is an important point of distinction in view of the Department’s increasing interest in extending its jurisdictionand enforcement authority over provider groups. Physicians and physician groups wouldbe well-advised to consider carefully their division of responsibility with their contractingpartners.The effect of the new regulation is to impose identical obligations for the HMO and PPOmarkets. While not widely known, the DMHC regulates over two-thirds of the PPOmarket in California in that it licenses both Anthem Blue Cross and Blue Shield ofCalifornia PPO plans. These carriers also seek licensing approval for certain of theirPPO products from the Department of Insurance. Individual physicians, as well ascertain medical groups, will execute “all-line” contracts with one or both of thesecarriers, covering both HMO and PPO patients. Due solely to their inability to distinguishthe particular regulator behind any specific PPO plan, and not as a result of an explicitrequirement of the CDI version of the regulation, certain providers ultimately willprovide the DMHC with time-elapse standards for all PPO patients. Higher compensationrates may be warranted to offset the cost impact of this regulatory confusion.
- For purposes of the timely access rule, the requirements placed upon Knox-Keene healthplans ultimately are non-delegable. Plans remain responsible to ensure that timely accessis provided regardless of their arrangements with contracted providers.25The regulation specifies health plan requirements for monitoring and reporting.Pursuant to its terms, health plans must report initially and frequently on the adequacy oftheir provider networks.26 The Department will initiate a workgroup comprised of industry members to evaluate and recommend monitoring strategies and to provideinformation to the DMHC about current capabilities. The DMHC Division of Surveys istasked with the periodic monitoring of the plans’ compliance with the regulation. Planswill be required to report on the specific composition of their contracted providernetworks in accordance with classifications promoted by the American Board of MedicalSpecialties.27 Plans also will be charged with monitoring advanced access programs on aquarterly basis, and, moreover, will be expected to devise a method to evaluate whethersuch systems are performing in compliance with the regulation.28 Finally, plans will betasked with conducting annual enrollee and provider satisfaction surveys and withreporting the results to the Department by March 31, 2012.29 Development of thesubstance and standards of the required provider and patient satisfaction survey isunderway as part of the Department’s implementation workgroup, but the extent ofmodification to the existing survey process that will occur remains uncertain. TheDepartment has committed to posting responses to “Frequently Asked Questions” on itswebsite to address questions raised by the public, providers, and plans.A thirty-minute triage requirement looms ominously. Perhaps the greatest challenge forall parties under this new regulation is the commonly-referred to “triage and screeningwait time” clause that requires telephone triage or screening response services within 30minutes of an enrollee call.30 The specific requirement concerning which type ofqualified personnel may respond has been a thorny issue. Consumer advocates arguedfor the provision of telephone access to nurses, if not to physicians, on a twenty-four hour/seven day a week basis. The final language of the regulation does not extend nearlythat far, but provides as follows:(i) A plan that arranges for the provision of telephone triage or screening servicesthrough contracted primary care and mental health care providers shall requirethose providers to maintain a procedure for triaging or screening enrolleetelephone calls, which, at a minimum, shall include the employment, duringand after business hours, of a telephone answering machine and/or ananswering service and/or office staff, that will inform the caller:a. Regarding the length of wait for a return call from the provider; andb. How the caller may obtain urgent or emergency care including, whenapplicable, how to contact another provider who has agreed to be on callto triage or screen by phone, or if needed, deliver urgent oremergency care(ii) A plan that arranges for the provision of triage or screening services throughcontracted primary care and mental health care providers who are unable tomeet the time-elapsed standards established in paragraph (8) (A) shall alsoprovide or arrange for the provision of plan-contracted or operated triage orscreening services, which shall, at a minimum, be made available to enrolleesaffected by that portion of the plan’s network.(iii) Unlicensed staff persons handling enrollee calls may ask questions on behalfof a licensed staff person in order to help ascertain the condition of an enrolleeso that the enrollee can be referred to licensed staff. However, under nocircumstances shall unlicensed staff persons use the answers to those questions in an attempt to assess, evaluate, advise, or make any decisionregarding the condition of an enrollee or determine when an enrollee needs tobe seen by a licensed medical professional.”The latter subsection concerning the qualifications of unlicensed staff persons and thescope of their handling of calls will undoubtedly reap havoc for solo and small-practicephysicians providing services under PPO contracts. The Department has clarified itsintent that this provision of the regulation requires “that the person performing the triageor screening must be a health care professional[,]”31 and, as well, that the purpose of therequirement is “determining the relative urgency of an enrollee’s need for care.”32In contracting with physician providers, health plans likely will retain the responsibilityto provide this level of compliance, since most solo and small-practice physicians will beunable to comply on their own. Some of the larger health plans currently have thecapability to provide “24/7” nurse advice lines. It became apparent during the finalstages of the regulatory hearing process that the DMHC intended that all HMOs and theirproviders develop such a capability, regardless of the cost impact to the industry.The DMHC concluded that it had to integrate the provisions of its previously adoptedLanguage Assistance Regulation (Title 28 Section 1300.67.04) with this regulation. Theadopted version of the timely access rule thus requires: “Interpreter services…shall becoordinated with scheduled appointments…in a manner that ensures the provision ofinterpreter services at the time of the appointment.”33 Consumer advocates were adamantthroughout the process that “language assistance” be provided under the newly established time-elapse standards. During the past two years, it has become apparent thatmost capitated-delegated physician groups declined to accept the delegation ofinterpretive services in their plan-provider contracts. For this reason, the plans will facethe greatest burden to coordinate language assistance services within the time-elapsestandards for timely access. For those provider groups that have assumed the delegatedobligation to provide interpretive services during patient visits, it would be prudent toconsider how the new timely access requirements will fit within their risk agreement.
- Dental, Chiropractic, Vision and Acupuncture specialty plans are also included in theregulation, but to a lesser extent and limited to subsections (c), (d) and (g), whichaddress portions of the requirements for standards, quality assurance processes, andfiling and reporting.For Dental plans, subsection (c) (6) sets forth the three time-elapse standards, for urgentcare appointments (within 72 hours), non-urgent appointments (within 36 business days),and preventive care (within 40 business days).The “24/7” triage and screening wait time requirement is substantially lessened for thesespecialty plans, which are required to maintain an answering service or message line thatexplains how enrollees may obtain urgent or emergency care.34 Mental Health plans will face unique challenges in meeting the fifteen business day rulefor specialist referral to psychiatrists. Whether this time-elapse standard applies toMFCCs remains an open issue, since the term “specialist” is not defined in this instance.All of the specialty plans will confront challenges meeting the ten minute customerservice time-elapse standard under subsection (c) (10).
- The regulation imposes a timeliness requirement for ancillary services. As finalized, thetimely access rule is explicitly limited to non-emergency services. As such, it excludessome of the most common patient encounters occurring in emergency departments. The regulation intersects with the business operations of hospitals concerning ancillaryservices, many of which are provided for in non-emergent cases in a hospital-basedsetting. The pertinent provision states:(F) Non-urgent appointments for ancillary services for the diagnosis or treatmentof injury, illness, or other health condition: within fifteen business days of therequest for appointment, except as provided in (G) and (H);24It is relatively uncertain at this point how hospitals and hospital-based ancillary serviceproviders will develop systems to comply with the rule and report back to theircontracting health plans. However, these constituents of the provider community shouldbe expected to look for ways to pass along their increased operational overhead to healthplans with which they contract.
- In determining a plan’s compliance or non-compliance with the requirements of this section, the Department will focus more upon patterns of non-compliance than isolated episodes of non-compliance and may consider all relevant factors, including but not limited to: (A) The efforts by a plan to evade the standards, such as referring enrollees to providers who are not appropriate for an enrollee’s condition; (B) The nature and extent of a plan’s efforts to avoid or correct non-compliance, including whether a plan has taken all necessary and appropriate action to identify the cause(s) underlying identified timely access deficiencies and to bring its network into compliance; (C) The nature of physician practices, including group and individual practices, the nature of a plan’s network, and the nature of the health care services offered; (D) The nature and extent to which a single instance of non-compliance results in, or contributes to, serious injury or damages to an enrollee; and (E) Other factors established in relevant provisions of law, and other factors that the Director deems appropriate in the public interest and consistent with the intent and purpose of the Act as applied to specific facts or circumstances.
- With the passage of federal health care reform, the CHCF now predicts that up to 6 million Californians will obtain coverage by 2014. Providers have for some time been trying to point out that with health reform, we can expect a tsunami of new patients with differed care needs. This will place a burden on providers to meet the demands regardless of whether the timely access requirements govern or not. Like the widespread adoption of advanced access by provider groups without any statutory or regulatory insistence or incentives, the California health care system is going to have to adopt to a universal coverage environment and continue to respond to consumerism trends.