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§ 1300.67.2.3. Timely Access Quality Assurance for Measurement Year 2022.

28 CA ADC § 1300.67.2.3Barclays Official California Code of RegulationsEffective: April 1, 2022

Barclays California Code of Regulations
Title 28. Managed Health Care
Division 1. The Department of Managed Health Care
Chapter 2. Health Care Service Plans (Refs & Annos)
Article 7. Standards
Effective: April 1, 2022
28 CCR § 1300.67.2.3
§ 1300.67.2.3. Timely Access Quality Assurance for Measurement Year 2022.
Currentness
(a) Quality Assurance Processes for Measurement Year 2022. Each plan shall have written quality assurance systems, policies and procedures designed to ensure that the plan's network is sufficient to provide accessibility, availability and continuity of covered health care services as required by the Knox-Keene Act and this section. In addition to the requirements established by Rule 1300.70, 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 Rule 1300.67.2.2(c);
(B) Conducting an annual enrollee experience survey, which shall be conducted in accordance with a valid and reliable survey methodology and designed to ascertain compliance with the standards set forth at Rule 1300.67.2.2(c);
(C) Conducting an annual provider survey, which shall be conducted in accordance with a 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 Rule 1300.67.2.2(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 network providers, medical groups and independent practice associations to confirm that appointments are scheduled consistent with the definition of advanced access in Rule 1300.67.2.2(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 (a)(2)(A) and (D) of this Rule by monitoring, on not less than an annual basis the following: the number of PPO primary care and specialty physicians under contract with the plan in each county of the plan's network service area; enrollee grievances and appeals regarding timely access; and the rates of compliance with the time-elapsed standards established in Rule 1300.67.2.2, subsection (c)(5).
(3) A plan shall implement prompt investigation and corrective action when compliance monitoring discloses that the plan's network is not sufficient to ensure timely access as required by this section, including 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 network 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.
(b)(1) The definitions in Rule 1300.67.2.2 shall apply for the purpose of this section, except as specified in Rule 1300.67.2.3, subsection (b)(2).
(2) The definition set forth in Rule 1300.67.2.2(b)(12)(A) shall not apply to reports or reviews for compliance pursuant to this section.
(c) This section shall become inoperative on January 1, 2023.

Credits

Note: Authority cited: Sections 1344, 1346 and 1367.03, Health and Safety Code. Reference: Sections 1342, 1367, 1367.01, 1367.03, 1367.035, 1367.04, 1370, 1371.31, 1375.7 and 1380, Health and Safety Code.
History
1. New section filed 3-16-2022; operative 4-1-2022 pursuant to Government Code section 11343.4(b)(3). Submitted to OAL for filing and printing only pursuant to Government Code section 11343.8. Exempt from the APA pursuant to Health and Safety Code section 1367.03(f)(3) (Register 2022, No. 11).
This database is current through 4/26/24 Register 2024, No. 17.
Cal. Admin. Code tit. 28, § 1300.67.2.3, 28 CA ADC § 1300.67.2.3
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