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§ 1300.67.2.2. Timely Access to Non-Emergency Health Care Services and Annual Timely Access and...

28 CA ADC § 1300.67.2.2Barclays Official California Code of RegulationsEffective: March 6, 2024

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: March 6, 2024
28 CCR § 1300.67.2.2
§ 1300.67.2.2. Timely Access to Non-Emergency Health Care Services and Annual Timely Access and Network Reporting Requirements.
Currentness
(a) Application.
(1) A health care service plan that provides or arranges for the provision of hospital or physician services, including a specialized mental health plan that provides physician or hospital services, or provides mental health services pursuant to a contract with a full-service plan, shall comply with the requirements of this section. A specialized mental health plan includes a plan only licensed to provide the services set forth in subsection (a)(3) of Health and Safety Code section 1374.72.
(2) A specialized dental, vision, chiropractic, or acupuncture plan shall comply with this subsection and subsections (c)(1), (c)(3), (c)(4), (c)(7), (c)(9), (c)(10), (d)(1), (g)(1), (h)(1)(B), (h)(5), (h)(9), (i) and (j) of this Rule. These specialized plans shall comply with the network access profile requirements in subsections (h)(2) and (h)(8) of this Rule, and documents incorporated within this Rule, as specified. Dental plans shall also comply with subsection (c)(6).
(3) The obligation of a plan to comply with this section shall not be waived if the plan delegates to its provider groups 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 Health Care Providers' Bill of Rights, and a material change in the obligations of a plan's network providers shall be considered a material change to the provider contract, within the meaning of subsections (b) and (h)(2) of section 1375.7 of the Knox-Keene Act.
(4) This section confirms requirements for plans to provide or arrange for the provision of health care services in a timely manner, and establishes additional metrics for measuring and monitoring the adequacy of a plan's 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.
(5) All reports and information submitted by the plan pursuant to this section shall be timely, accurate and complete.
(6) A plan that uses a tiered network shall demonstrate compliance with the standards established by section 1367.03 of the Knox-Keene Act and this Rule based on providers available at the lowest cost-sharing tier.
(b) Definitions.
For purposes of this section, the following definitions apply.
(1) “Advanced access” means the provision, by a network provider, or by the provider group 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.
(2) “Appointment waiting time” means the time from the initial request to the plan or a provider for covered health care services by an enrollee, an enrollee's representative or the enrollee's treating provider to the earliest date offered for the appointment for services. Appointment waiting time is inclusive of time for obtaining authorization from the plan or completing any other condition or requirement of the plan or its network providers. A grievance, as defined in Rule 1300.68(a)(1), regarding a delay or difficulty in obtaining an appointment for a covered health care service may constitute an initial request for an appointment for covered health care services.
(3) “Preventive care” means health care provided for prevention and early detection of disease, illness, injury, or other health conditions and, in the case of a full-service plan includes all of the following health care services required by sections 1345(b)(5), 1367.002, 1367.3 and 1367.35 of the Knox-Keene Act, and Rule 1300.67(f).
(4) “Measurement year” means the time periods within which a plan shall collect the required information for the Timely Access Compliance Report and the Annual Network Report.
(A) The Timely Access Compliance Report measurement year is January 1 to December 31 of the year immediately preceding the year in which the information set forth in subsection (h)(6), (h)(7)(A)(iv), and (h)(7)(C) of this Rule is required to be submitted to the Department, pursuant to subsection (h)(1) of this Rule.
(B) The Annual Network Report measurement year is the year in which the information set forth in subsection (h)(7) of this Rule is required to be submitted to the Department, pursuant to subsection (h)(1) of this Rule, except as otherwise indicated in subsections (h)(7)(A)(iv) and (h)(7)(C) of this Rule.
(5) “Network” means a discrete set of network providers, as defined in subsection (b)(10) of this Rule, the plan has designated to deliver all covered services for a specific network service area, as defined in subsection (b)(11) of this Rule.
(6) “Network adequacy” means the sufficiency of a plan's network to ensure the delivery of all covered services, on an ongoing basis, in a manner that meets the network accessibility, availability, and capacity requirements set forth in the Knox-Keene Act, including subsection (a)(5) of section 1371.31, subsections (d) and (e) of section 1367 and section 1375.9, and Rules 1300.51, 1300.67.2, subsection (c)(7) of this Rule, and 1300.67.2.1.
(7) “Network capture date” means the date the plan shall capture all data for each network required to be reported pursuant to subsections (h)(6)(B)(i)a.-e. and (h)(7)(A)(i)-(iii) of this Rule, for the Timely Access Compliance Report and the Annual Network Report. The following network capture dates apply:
(A) For the Annual Network Report, the network capture date is January 15 of the Annual Network Report measurement year, as set forth in subsection (b)(4)(B) of this Rule.
(B) For the Timely Access Compliance Report, the network capture date is a date selected by the plan that occurs on or after January 15 of the Timely Access Compliance Report measurement year as set forth in subsection (b)(4)(A) of this Rule, but no later than the date the plan begins conducting the Provider Appointment Availability Survey, set forth in subsection (f) of this Rule. The network capture date selected by the plan shall:
(i) Allow the plan to adhere to all requirements in the PAAS Manual;
(ii) Be a date as close to administration of the survey as practicable; and
(iii) Ensure the information in the plan's Provider Appointment Availability Survey Contact List is accurate and representative of the network at the time the survey is administered.
(8) “Network identifier” is the fixed identifier assigned to each network by the Department.
(9) “Network name” is the name used by the plan to identify a specific network in plan communications and submissions to the Department.
(10) “Network provider” means any provider as defined in subsection (i) of section 1345 of the Knox-Keene Act, located inside or outside of the network service area of a designated network, meeting all of the following criteria:
(A) The provider is available to provide covered services to all plan enrollees in all product lines using the designated network.
(B) The provider is one or more of the following:
(i) An employee of the plan;
(ii) An individual health professional or health facility contracted directly with the plan consistent with the Knox-Keene Act and implementing regulations, including the contractual requirements for providers within sections 1348.6, 1367(h), 1367.04, 1367.27, 1367.62, 1373.65(f), 1375.7, 1379 and subsection (d) of section 1351;
(iii) An individual health professional or health facility contracted with the plan through an association, provider group, or other entity, consistent with the Knox-Keene Act and implementing regulations, including the contractual requirements for providers within sections 1348.6, 1367(h), 1367.04, 1367.27, 1367.62, 1373.65(f), 1375.5, 1379, and subsection (d) of 1351;
(iv) An individual health professional or health facility designated to deliver covered services to enrollees in the network through a plan-to-plan contract, as defined in subsection (b)(13); or
(v) An individual health professional or health facility required to be part of the plan's network under any of the following circumstances;
a. a corrective action plan submitted to the Department by the plan or its delegated entity;
b. as required by the Department pursuant to section 1373.65 of the Knox-Keene Act; or
c. as otherwise required by order of the Department.
(C) The provider is accessible to enrollees of the designated network without limitations other than established:
(i) In-network referral or authorization processes; or
(ii) Processes for changing provider groups consistent with section 1373.3 of the Knox-Keene Act, in networks where enrollees are assigned to a provider group.
(D) A network provider shall not include:
(i) Providers made available through single-case agreements, letters of intent, or contract agreements that do not include the provider contracting requirements of the Knox-Keene Act as described in subsection (b)(10)(B)(ii) and (iii) of this Rule;
(ii) For any line-of-business that includes an out-of-network benefit (e.g., preferred provider organization (PPO) or point-of-service (POS)), providers who are available to enrollees only at non-participating or out-of-network cost-share levels; or
(iii) Noncontracting individual health professionals, as defined in subsection (f)(5) of section 1371.9 of the Knox-Keene Act.
(11) “Network service area” means the geographical area, and population points contained therein, where the plan is approved by the Department to arrange health care services consistent with network adequacy requirements. “Population points” shall mean a representation of where people live and work in the state of California based on United States Census Bureau population data and United States Postal Service (USPS) delivery route data, and made available annually by the Department on the web portal accessible at www.dmhc.ca.gov.
(12) “Patterns of non-compliance,” with respect to the standards set forth in subsection (c) of this Rule, means any of the following:
(A) For purposes of the Provider Appointment Availability Survey: Fewer than 70% of the network providers, as calculated on the Provider Appointment Availability Survey Results Report Form, for a specific network had a non-urgent or urgent appointment available within the time-elapsed standards set forth in subsection (c)(5)(A)-(F) for the measurement year. A pattern of non-compliance shall be identified using the information reported to the Department in the “Rate of Compliance Urgent Care Appointments (All Provider Survey Types)” field and the “Rate of Compliance Non-Urgent Appointments (All Provider Survey Types)” field in the Summary of Rate of Compliance Tab of the Results Report Form.
(B) The Department receives information establishing that the plan was unable to deliver timely, available, or accessible health care services to enrollees. The Department may consider any of the following factors in evaluating whether each instance identified is part of a pattern of non-compliance that is reasonably related:
(i) Each instance is a violation of the same standard set forth in subsection (c) of this Rule;
(ii) Each instance involves the same network;
(iii) Each instance involves the same provider group, or subcontracted plan;
(iv) Each instance involves the same provider type;
(v) Each instance involves the same network provider;
(vi) Each instance occurs in the same region. For purposes of this subsection, a region is a county in which a network provider practices, and the counties next to or adjoining that county;
(vii) The number of enrollees in the health plan's network and the total number of instances identified as part of a pattern;
(viii) Whether each instance occurred within the same twelve-month period; or
(ix) Whether each instance involves the same category of health care services.
(13) “Plan-to-plan contract” means an arrangement between two plans, in which the subcontracted plan makes network providers available to primary plan enrollees, and may be responsible for other primary plan functions. Plan-to-plan contracts include administrative service agreements, management service agreements or other contracts between a primary and subcontracted plan.
(A) “Primary plan” means a licensed plan that holds a contract with a group, individual subscriber, or a public agency, to arrange for the provision of health care services.
(B) “Subcontracted plan” means a licensed plan or specialized plan that is contracted to allow a primary plan's enrollees access to the subcontracted plan's network providers. The contract may be between the primary plan and the subcontracted plan or between two subcontracted plans.
(14) “Product line” means the combination of the plan's product and the type of market segment (e.g., individual, large group, small group, government) in which the product is licensed to be offered. “Product” means a discrete package of health care benefits the plan is licensed to offer using a particular line of business (e.g., health maintenance organization (HMO), PPO, POS, and exclusive provider organization (EPO)) within a network service area.
(15) “Provider group” has the meaning set forth in subsection (g) of section 1373.65 of the Knox-Keene Act.
(16) “Provider Survey Types” means the following five types of network providers required to be surveyed in the Provider Appointment Availability Survey Manual, pursuant to subsection (f) of this section:
(A) Primary care providers;
(B) Non-physician mental health care providers;
(C) Specialist physicians;
(D) Psychiatrists; and
(E) Ancillary service providers.
(17) “Reporting plan” means a full-service or mental health plan that is licensed to contract with a group, individual subscriber, or a public agency, to arrange for the provision of health care services and has one or more networks approved by the Department as of January 15th of the applicable measurement year. A reporting plan shall submit the reports set forth in subsection (h) of this section on behalf of itself or on behalf of a subcontracted plan through a plan-to-plan contract.
(18) “Reporting year” means the calendar year in which the plan's Timely Access Compliance Report and Annual Network Report is submitted to the Department.
(19) “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 their 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.
(20) “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 their scope of practice and who is trained to screen or triage an enrollee who may need care.
(21) “Urgent care” means health care for a condition which requires prompt attention, consistent with subsection (h)(2) of section 1367.01 of the Knox-Keene Act.
(22) “Lowest cost-sharing tier” means a network tier or tiers that comprise the lowest cost-sharing available to all enrollees in the network for each provider type or covered service within a tiered network.
(A) “Network tier” means a discrete set of network providers within a tiered network that are available at a distinct cost-sharing level to all enrollees who use the network. Pursuant to subsection (b)(10)(D) of this Rule, a network tier does not include providers accessible to enrollees through an out-of-network benefit.
(B) A “tiered network” means a network in which enrollees have access to network providers of the same provider types, delivering the same category of services, at different copayment, coinsurance, deductible, or any other form of cost-sharing levels.
(C) The lowest cost-sharing tier shall meet the following criteria:
(i) The lowest cost-sharing tier shall be comprised of network providers of such types, numbers, and locations that comply with timely access and network adequacy standards set forth in the Knox-Keene Act and this Title, without relying on any network providers offered at higher cost-sharing levels or a different network tier of providers within the network;
(ii) The lowest cost-sharing tier shall be comprised of the same discrete set of providers available to all enrollees using the network; and
(iii) The lowest cost-sharing tier shall comprise the discrete set of providers considered when a plan is determining whether it must submit a network filing pursuant to Health and Safety Code sections 1352 and 1367.27(r), and Rules 1300.52(f), and 1300.67.2.1. For purposes of calculating the change in the number of providers under Health and Safety Code section 1367.27(r), and Rule 1300.52(f), for a tiered network, the plan shall calculate the change using only the network providers included in the lowest cost-sharing tier.
(D) A plan may offer a subset of network providers or covered services at a cost-sharing rate reduced below the lowest cost-sharing tier to some or all enrollees that use the designated network. Reduced cost-sharing shall be subject to the following requirements:
(i) The reduced cost-sharing rate shall be separately identified from the lowest cost-sharing rate in all enrollee-facing and marketing materials, including the schedule of benefits;
(ii) Enrollee-facing and marketing materials shall clearly indicate that a complete network is not available at the reduced cost-sharing rate;
(iii) Network providers available at a reduced cost-sharing rate may be included in a plan's lowest cost-sharing tier for the purposes of assessing compliance with timely access and network adequacy standards only if all enrollees have access to these providers either within the lowest cost-sharing tier, or at the reduced cost-sharing rate described in this subsection; and
(iv) A plan offering reduced a cost-sharing rate shall ensure it complies with all requirements set forth in Health and Safety Code section 1374.72.
(E) Pursuant to Health and Safety Code section 1367.03(a)(1), a plan's compliance with timely access and network adequacy standards shall be determined at the lowest cost-sharing tier, as described in subsections (b)(22)(C) and (b)(22)(D) of this Rule. A plan shall ensure that all plan operations, including internal monitoring processes, comply with this requirement. If an enrollee is unable to obtain a covered service in the lowest cost-sharing tier of a network within geographic and timely access standards set by law or regulation, a plan shall arrange for that service to be provided by a network provider in another tier or an out-of-network provider and ensure the enrollee is responsible for paying no more than the cost-sharing established for the lowest cost-sharing tier.
(F) Pursuant to Health and Safety Code section 1367.27(h)(12), a plan shall include information in the provider directory identifying the network tier to which the network provider is assigned, and whether a reduced cost-sharing rate is available.
(G) A plan shall not place restrictions on an enrollee's access to network providers or covered services within a tiered network, other than the established processes identified within subsection (b)(10)(C) of this Rule.
(H) A plan that is unable to meet network adequacy at the lowest cost-sharing tier under the definition set forth in this subsection may propose an alternative approach to determining which providers comprise the lowest cost-sharing tier. A plan shall justify any request for an alternative approach in accordance with the facts and circumstances set forth in subsection (c) of Rule 1300.67.2.1 and shall make the request via an initial application for licensure or a notice of material modification to the Department.
(c) Standards for Timely Access to Care.
(1) A plan 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. A plan shall establish and maintain networks, policies, procedures, and quality assurance monitoring systems and processes sufficient to ensure compliance with this clinical appropriateness standard.
(2) A plan shall ensure that all plan and provider processes necessary to obtain covered health care services, including the processes required under section 1367.01 of the Knox-Keene Act, are completed in a manner that assures the provision of covered health care services to an enrollee in a timely manner appropriate for the enrollee's condition and in compliance with the requirements of this Rule.
(3) If 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 Knox-Keene Act and the requirements of this Rule.
(4) Interpreter services required by section 1367.04 of the Knox-Keene Act and Rule 1300.67.04 shall be coordinated by the plan, its delegated network provider, or other delegated entity with scheduled appointments for health care services in a manner that ensures the provision of interpreter services at the time of the appointment without imposing delay on the scheduling of the appointment. This subsection does not modify the requirements established in Rule 1300.67.04 or approved by the Department pursuant to Rule 1300.67.04 for a plan's language assistance program.
(5) In addition to ensuring compliance with the clinical appropriateness standard set forth in subsection (c)(1) of this Rule, a plan shall ensure that its 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 subsection (c)(5)(H) of this Rule;
(B) Urgent care appointments for services that require prior authorization: within 96 hours of the request for appointment, except as provided in subsection (c)(5)(H) of this Rule;
(C) Non-urgent appointments for primary care: within ten business days of the request for appointment, except as provided in subsection (c)(5)(H) and in subsection (c)(5)(I) of this Rule;
(D) Non-urgent appointments with specialist physicians: within fifteen business days of the request for appointment, except as provided in subsection (c)(5)(H) and in subsection (c)(5)(I) of this Rule;
(E) Non-urgent appointments with a non-physician mental health care provider or substance use disorder provider: within ten business days of the request for appointment, except as provided in subsection (c)(5)(H) and in subsection (c)(5)(I) of this Rule;
(F) Nonurgent follow up appointments with a nonphysician mental health care or substance use disorder provider: within 10 business days of the prior appointment for those undergoing a course of treatment for an ongoing mental health or substance use disorder condition, except as provided in subsection (c)(5)(H) of this Rule. This subsection does not limit coverage for nonurgent follow up appointments with a nonphysician mental health care or substance use disorder provider to once every 10 business days.
(G) 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 subsection (c)(5)(H) and in subsection (c)(5)(I) of this Rule;
(H) 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 their 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;
(I) Preventive care services and periodic follow up care, including standing referrals to specialists for chronic conditions, periodic office visits to monitor and treat pregnancy, cardiac, mental health, or substance use disorder 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 their practice;
(J) A referral to a specialist by a primary care provider or another specialist shall be subject to the relevant time-elapsed standard in subsection (c)(5)(A), (B), or (D) of this Rule, unless the requirements in subsection (c)(5)(H) or (I) of this Rule are met, and shall be subject to the other provisions of this section; and
(K) 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) of this Rule.
(6) In addition to ensuring compliance with the clinical appropriateness standard set forth in subsection (c)(1) of this Rule, each dental plan, and each full-service plan offering coverage for dental services, shall ensure that dental 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, if 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) of this Rule; and
(C) Preventive dental care appointments shall be offered within 40 business days of the request for appointment.
(7) A plan shall ensure it has sufficient numbers of network providers to maintain compliance with the standards established by this section.
(A) This section does not modify the requirements regarding provider-to-enrollee ratios or geographic accessibility established by Rules 1300.51, 1300.67.2 or 1300.67.2.1.
(B) A plan operating in a network service area, or a portion of a network 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 organization or point-of-service network, by assisting an enrollee to locate, available and accessible network providers in neighboring network service areas consistent with patterns of practice for obtaining health care services in a timely manner appropriate for the enrollee's health needs.
(C) A plan shall arrange for the provision of covered services from providers outside the plan's network if unavailable within the network, if medically necessary for the enrollee's condition. A plan shall ensure that enrollee costs for medically necessary referrals to non-network providers under this Rule shall not exceed applicable in-network 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 network provider. If medically necessary treatment of a mental health or substance use disorder is not available in network within the geographic and timely access standards set by law or regulation, a plan shall arrange coverage outside the plan's network in accordance with subsection (d) of section 1374.72 of the Knox Keene Act.
(8) A plan 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)(19) of this Rule.
(A) A plan shall ensure that telephone triage or screening services are provided in a timely manner appropriate for the enrollee's condition, and 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)(19) of this Rule; telephone medical advice services pursuant to section 1348.8 of the Knox-Keene Act; the plan's contracted primary care and mental health care or substance use disorder network; or another method that provides triage or screening services consistent with the requirements of this subsection.
(i) A plan that arranges for the provision of telephone triage or screening services through primary care, mental health care, and substance use disorder network 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, an answering service, or office staff, that shall inform the caller of both of the following:
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 telephone, or if needed, deliver urgent or emergency care.
(ii) A plan that arranges for the provision of triage or screening services through network primary care, mental health care and substance use disorder providers who are unable to meet the time-elapsed standards established in subsection (c)(8)(A) shall also provide or arrange for the provision of plan-contracted or plan-operated triage or screening services, which shall, at a minimum, be made available to enrollees affected by that portion of the plan's network.
(iii) An unlicensed staff person 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 may be referred to a licensed staff person. However, an unlicensed staff person shall not, under any circumstances, use the answers to those questions 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) A plan that provides dental, vision, chiropractic, or acupuncture services shall ensure that network providers delivering these health care services employ an answering service or a telephone answering machine during non-business hours that provides instructions regarding how an enrollee may obtain urgent or emergency care, including, if applicable, how to contact another provider who has agreed to be on-call to triage or screen by telephone, or if needed, deliver urgent or emergency care.
(10) A plan 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.
Effective January 1, 2023, 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 Rule. 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 network providers including:
(A) Tracking and documenting network capacity and availability with respect to the standards set forth in:
(i) Subsections (c)(1)-(4), (c)(5)(H)-(K), (c)(6), and (c)(8)-(10) of this Rule, except as provided by subsection (d)(2)(F) of this Rule;
(ii) Subsection (c)(7) of this Rule; and
(iii) Subsection (c)(5)(A)-(G) of this Rule by administering the Provider Appointment Availability Survey, pursuant to subsection (f) of this Rule.
(B) Conducting an annual Enrollee Experience Survey. The Enrollee Experience Survey shall:
(i) Be conducted in accordance with a statistically valid and reliable survey methodology.
(ii) Obtain enrollees' perspectives and concerns regarding their experience obtaining health care services within the standards set forth in subsection (c) of this Rule.
(iii) Inform enrollees of their right to obtain an appointment within each of the time-elapsed standards set forth in subsections (c)(1) and (5) of this Rule, and their right to receive interpreter services at that appointment, as required by subsection (c)(4) of this Rule. The requirement to notify enrollees who are surveyed about their right to obtain a timely appointment shall be in addition to the notice requirements set forth in section 1367.031 of the Knox-Keene Act. The notice may be included in the survey or in a document attached to the survey.
(iv) Evaluate the experience of limited English proficient enrollees in obtaining interpreter services by obtaining the enrollee's perspectives and concerns regarding:
a. Coordination of appointments with an interpreter;
b. Availability of interpreters who speak the enrollee's preferred language; and
c. Quality of interpreter services received.
(v) Be translated into the enrollee's preferred language, in those situations where:
a. The plan is aware of the enrollee's preferred language; and
b. The enrollee's preferred language is one of the top 15 languages spoken by limited English proficient individuals in California as determined by the Department of Health Care Services.
(C) Conducting an annual Provider Satisfaction Survey, which shall be conducted in accordance with a statistically valid and reliable survey methodology and designed to obtain, from physicians and non-physician mental health providers, perspectives and concerns regarding compliance with the standards set forth in subsection (c). In addition, the Provider Satisfaction Survey shall evaluate provider perspectives and concerns with the plan's language assistance program regarding:
(i) Coordination of appointments with an interpreter;
(ii) Availability of an interpreter, based on the needs of the enrollee; and
(iii) The ability of the interpreter to effectively communicate with the provider on behalf of the enrollee.
(D) The plan's process for reviewing and evaluating, on not less than a quarterly basis, all the information available to the plan regarding the plan's ability to meet timely access compliance and network adequacy requirements set forth under the Knox-Keene Act, including accessibility, availability, continuity of care, and network capacity requirements. The plan's review and evaluation shall include, at a minimum, the information from its quality assurance processes required under sections 1367, 1367.03, 1370 of the Knox-Keene Act, and Rules 1300.67.2, 1300.67.2.2, 1300.68, and 1300.70. The plan's process for reviewing and evaluating available information shall ensure that enrollees have access to the full range of covered services through an adequate network, as required under this Rule, and sections 1367, 1367.03, 1367.035, and 1375.9 of the Knox-Keene Act, and Rules 1300.51(d), items H., I., and J., and 1300.67.2.
(E) Verifying, at least once every three years, the advanced access programs reported by network providers and provider groups by confirming that appointments are scheduled consistent with the definition of advanced access in subsection (b)(1). The plan shall require network providers to give written notice to the plan no later than 30 calendar days immediately following the date upon which a network provider no longer provides advanced access appointments to enrollees. The plan shall also review the available information related to access and availability for providers offering advanced access appointments, including enrollee grievances and appeals, pursuant to subsection (d)(2)(D) of this Rule.
(F) A plan that provides services through a preferred provider organization line of business may, for that product line, demonstrate compliance with the timely access and continuity of care requirements of subsection (d)(2)(A)(i) of this Rule by monitoring, on not less than an annual basis: enrollee grievances and appeals regarding timely access; the results of the Provider Appointment Availability Survey; the results of the Enrollee Experience Survey; and the results of the Provider Satisfaction Survey. This subsection does not exempt a plan that provides services through a preferred provider organization line of business from all other requirements set forth in subsection (d)(2).
(3) A plan's process for documenting and implementing prompt investigation and corrective action when compliance monitoring discloses that the plan's network is not sufficient to ensure timely access and network adequacy as required by this Rule. A plan's quality assurance process shall ensure the plan takes all necessary and appropriate action to identify the cause(s) underlying identified timely access and network adequacy deficiencies and to bring its network into compliance. A plan 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.
(e) Enrollee Disclosure and Education.
(1) A plan shall disclose in all Evidences of Coverage the availability of triage or screening services and how to obtain those services. A plan shall disclose standards for timely access in the manner required under section 1367.031 of the Knox-Keene Act.
(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) Provider Appointment Availability Survey.
(1) Beginning January 1, 2023, and annually thereafter, a plan shall demonstrate that each of its networks has adequate capacity and availability of network providers sufficient to offer enrollees appointments within the standards set forth in subsection (c)(5)(A)-(G) by administering the Provider Appointment Availability Survey, and reporting rates of compliance for each network. When conducting the Provider Appointment Availability Survey, the plan shall follow all requirements in the Provider Appointment Availability Survey Manual, which is hereby incorporated by reference, and the Timely Access Submission Instruction Manual, which is hereby incorporated by reference. A plan shall use the versions of the Provider Appointment Availability Survey Manual and the Timely Access Submission Instruction Manual noticed on the Department's website at www.dmhc.ca.gov, on or before May 1 of the measurement year. In conducting the Provider Appointment Availability Survey, a plan must do all of the following:
(A) Determine the networks required to be surveyed;
(B) Complete a Contact List Report Form for each of the applicable Provider Survey Types;
(C) Determine the number of network providers from which the plan is required to obtain survey responses to meet the required sample size;
(D) Select the network providers to be surveyed for each network;
(E) Prepare the survey questions;
(F) Administer the Provider Appointment Availability Survey using one or more of the three modalities set forth in Provider Appointment Availability Survey Manual: Extraction, the Three Step Protocol, or a Qualified Advanced Access Provider. If a plan uses the Three Step Protocol, the plan shall adhere to the following timeframes in conducting the survey:
(i) All surveys shall be completed, including any required follow-up calls, within 17 business days of sending the initial survey invitation via email, electronic communication, or fax. If an email, electronic communication, or fax survey invitation cannot be sent to a provider, because the appropriate contact was not available or the provider prefers to be contacted by telephone, the survey shall be completed by telephone within 5 business days from the date of the initial telephone call.
(ii) If the provider has not responded within 2 business days of sending the initial survey invitation, a reminder notice may be sent to the provider.
(iii) If the provider does not respond to the survey within 5 business days of the plan sending the survey invitation, the plan shall initiate the survey via telephone within 6-15 business days of sending the initial survey invitation.
(iv) If a provider's office does not answer the initial call, the plan shall call the provider back on or before the next business day to initiate the telephone survey. The plan may leave a telephone message requesting that the provider complete the survey via a call back number and/or email, electronic communication, or fax, within 2 business days of the telephone message.
(v) If a provider declines to respond to the survey, the plan shall offer the provider's office the option to respond at a later time. If the provider is willing to participate at a later time, the plan shall offer the provider the option to receive a follow-up call within the next 2 business days.
(vi) If the provider does not complete the telephone survey within 2 business days of the initial telephone call or the telephone message left requesting the provider complete the survey or during the follow-up telephone call, the non-responding provider shall be replaced with a provider from the oversample.
(vii) If the plan was unable to initiate a telephone survey of the provider within 6-15 business days of sending the initial survey attempt conducted via email, electronic communication or fax, the provider shall be recorded on the Raw Data Report Form as a non-responder and replaced with a provider from the oversample.
(G) Record the survey outcome, the provider's survey responses, and compliance determinations on the Raw Data Report Form;
(H) Calculate and record the results of the Provider Appointment Availability Survey on the Results Report Form;
(I) Identify whether each network met or exceeded the threshold rates of compliance set forth in subsection (b)(12)(A). If a network failed to meet or exceed the threshold rates of compliance, the plan shall implement prompt investigation and corrective action, as required by subsection (d)(3), to bring the network into compliance with this section;
(J) Conduct the quality assurance review and create the quality assurance report; and
(K) Submit the plan's Timely Access Compliance Report, in accordance with the requirements set forth in subsection (h) and the Timely Access and Annual Network Submission Instruction Manual.
(2) A plan shall complete the report forms identified in subsection (h)(6)(B) in accordance with the requirements set forth in the Provider Appointment Availability Survey Manual and Timely Access Submission Instruction Manual. A plan's final rates of compliance shall be determined and calculated in accordance with all requirements and instructions set forth in the Provider Appointment Availability Survey Manual and the Timely Access Submission Instruction Manual. A plan shall report rates of compliance that include survey results from network providers made available to the plan through a plan-to-plan contract with a subcontracted plan.
(3) After the annual Provider Appointment Availability Survey has been completed, a plan shall have an external vendor, who is not affiliated with the plan, conduct a quality assurance review. The quality assurance review shall be documented in a quality assurance report prepared by the plan's external vendor. The quality assurance review and report shall meet all requirements set forth in the Provider Appointment Availability Survey Manual. The quality assurance review shall ensure that:
(A) The plan followed all statutory and regulatory requirements related to the Provider Appointment Availability Survey, the Provider Appointment Availability Survey Manual, and Provider Appointment Availability Survey Report Form Instructions, as set forth in the Timely Access Submission Instruction Manual.
(B) All information in the plan's Provider Appointment Availability Survey Report Forms submitted to the Department is true, complete, and accurate.
(4) A plan shall ensure the following actions are conducted in accordance with the Provider Appointment Availability Manual and the Timely Access Submission Instruction Manual:
(A) Gathering information and data to complete the Provider Appointment Availability Survey Report Forms.
(B) Validating the information and data included in the Provider Appointment Availability Survey Report Forms, set forth in (h)(6)(B)(i), and correcting any errors.
(C) Verifying all providers in the plan's Provider Appointment Availability Survey Report Forms meet all eligibility criteria.
(D) Reporting any errors the plan did not correct and identifying the steps the plan will take to ensure compliance with the Provider Appointment Availability Survey Manual and Provider Appointment Availability Survey Report Form Instructions, as set forth in the Timely Access Submission Instruction Manual in future reporting years. Nothing in this section shall relieve the plan of its obligation to report accurate information and data in the Timely Access Compliance Report submitted to the Department pursuant to subsection (h)(6).
(5) A plan shall not require or instruct network providers to hold appointments open that are not available to patients for the purpose of satisfying appointment waiting time standards set forth under subsection (c)(5)(A)-(G).
(6) This subsection (f) does not modify the requirements of a plan to maintain a network sufficient to provide timely access and network adequacy as set forth in subsection (c) and the Knox-Keene Act.
(g) Requests for Alternative Access Standards.
In addition to a plan's ability to request alternative time and distance standards and alternative provider to enrollee ratios pursuant to Rule 1300.67.2.1, a plan may also file a notice of material modification to request the Department's approval of alternative time-elapsed standards, alternatives to time-elapsed standards, or an alternative standard for the threshold rates of compliance set forth in the definition of patterns of non-compliance in subsection (b)(12)(A).
(1) A request for an alternative time-elapsed standard or an alternative to time-elapsed standards shall include:
(A) 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 network providers;
(B) Information demonstrating and substantiating why a proposed alternative standard is more appropriate than the standards set forth in subsection (b)(12)(A) and subsection (c);
(C) A description of all the steps the plan has taken, and any additional steps the plan will take to demonstrate its reasonable efforts, to bring its network into compliance with the existing standards set forth under Rule 1300.67.2.2, including contracting with additional providers. The description shall include how the request for the alternative standard will address any changes or deficiencies noted by the health plan between the results of the current and prior year's Provider Appointment Availability Surveys;
(D) For a plan that received approval for an alternative standard, filing, 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;
(2) In approving or disapproving a plan's proposed alternative standards, the Department may consider all relevant factors, including the factors set forth in subsections (d) and (e) of section 1367.03 of the Knox-Keene Act and subsection (c) of Rule 1300.67.2.1.
(3) The Department may consider the information submitted by the plan pursuant to subsection (h), and information related to monitoring of networks as set forth in subsection (d) of this Rule and subsections (d)-(f) of Rule 1300.67.2.
(4) A request for an alternative standard to the threshold rates of compliance set forth in subsection (b)(12)(A) of this Rule, shall include the information set forth under subsection (g)(1)(B)-(C) and shall be subject to subsections (g)(2) and (g)(3) of this Rule.
(h) Filing, Implementation and Reporting Requirements.
(1) The requirements set forth in subsection (h)(6)-(8) of this Rule shall apply only to reporting plans, except as specified in (h)(1)(B) of this Rule. Except as specified in subsection (h)(5) of this Rule, this subsection (h) shall be effective on and after January 1, 2023.
(A) By May 1 of each year, a reporting plan shall file with the Department a Timely Access Compliance Report, as described in subsection (h)(6) of this Rule, and an Annual Network Report, as described in subsection (h)(7) of this Rule, except as otherwise described in subsection (h)(4) of this Rule. Both reports shall include the network access profile, as set forth in subsection (h)(8) of this Rule.
(B) By May 1 of each year, a subcontracted plan for one or more of the networks identified in subsection (h)(1)(A) of this Rule, and a plan set forth in subsection (a)(2) of this Rule, shall complete only the network access profile, as set forth in subsections (h)(8)(A)-(C) of this Rule. This subsection and subsections (h)(2)-(h)(3), (h)(5), (h)(9) and the requirements to complete the Annual Network Report section of the network access profile in subsections (h)(4)(A)(iv)b. and (h)(4)(B) of this Rule shall apply to plans that do not meet the definition of a reporting plan, as set forth in subsection (b)(17) of this Rule. This subsection shall not apply to any plan that meets the description set forth in subsection (h)(1)(A) of this Rule.
(2) A reporting plan shall submit the Timely Access Compliance Report and Annual Network Report using report form templates issued by the Department pursuant to this section. All health plans shall designate an individual as a compliance officer who shall be responsible for reviewing and submitting the required reports and information, and verifying, pursuant to Rule 1004, that the information and data submitted within the reports and the network access profile is true and correct and does not contain misstatements or omissions of material fact. All plans shall submit the required report forms and information through the Department's web portal, accessible at www.dmhc.ca.gov.
(3) Beginning with measurement year 2023, when reporting networks that include network providers made available through plan-to-plan contracts, the primary plan is the reporting plan for the network, and is responsible for submitting all information and data, including the Timely Access Compliance Report and the Annual Network Report, as described in subsections (h)(1)(A), (h)(6)(B)-(G) and (h)(7) of this Rule, on an annual basis. The subcontracted plan for a network is subject to the reporting requirements set forth in subsection (h)(1)(B) of this Rule. The primary plan's submission shall include all network providers, enrollment, grievance and other required data set forth in these subsections, whether maintained by the plan, a subcontracted plan, or a delegated provider group.
(4) Implementation Reporting.
(A) For reporting year 2023, a plan shall submit:
(i) The Timely Access Compliance Report, as set forth in (h)(6) of this Rule, unless otherwise specified, reported according to the measurement year set forth in subsection (b)(4)(A) of this Rule. A plan shall submit the measurement year 2022 Provider Appointment Availability Survey data required in subsection (h)(6)(B) of this Rule using the methodology and report forms described in the plan's policies and procedures filed with the Department for measurement year 2022.
(ii) The Annual Network Report, as set forth in subsection (h)(7) of this Rule, reported according to the measurement year set forth in subsection (b)(4)(B) of this Rule, and the network capture date set forth in subsection (b)(7)(A) of this Rule.
(iii) Grievance data as described in subsection (h)(7)(A)(iv) of this Rule, and the Out-of-Network Payment Report Form as described in (h)(7)(C) of this Rule, reported according to the measurement year set forth in subsection (b)(4)(A) of this Rule.
(iv) The network access profile information, as set forth in subsection (h)(8) of this Rule, with the following:
a. December 31, 2021 as the Timely Access Compliance Report network capture date, and
b. The network capture date set forth in subsection (b)(7)(A) of this Rule for the Annual Network Report.
(B) Beginning in reporting year 2024, a plan shall submit the Timely Access Compliance Report, the Annual Network Report, and accompanying network access profile information as set forth in subsections (h)(6)(B), (h)(7)(A)(i)-(iii), and (h)(8) of this Rule, using the network capture date, defined in subsection (b)(7) of this Rule for the applicable measurement year.
(5) Implementation Policies and Procedures. Within three months following the effective date of this section, a plan shall file an amendment pursuant to section 1352 of the Knox-Keene Act disclosing how the plan will achieve compliance with the requirements of this Rule. The submission shall include policies and procedures necessary for compliance with the requirements of this Rule.
(6) Timely Access Compliance Report. A plan shall submit the items set forth in subsections (h)(6) and (h)(8) of this Rule, as part of its Timely Access Compliance Report for each applicable measurement year, as defined in (b)(4)(A) of this Rule. Each item shall be submitted in accordance with the requirements set forth in the Timely Access Submission Instruction Manual. The following items shall be included in the plan's Timely Access Compliance Report:
(A) The Department issued filing number for the plan's policies and procedures setting forth:
(i) The plan's timely access standards, consistent with the standards set forth in subsection (c), 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.
(ii) The plan's Quality Assurance Processes for monitoring each timely access standard and implementing corrective action, as set forth in subsection (d) of this Rule and the Provider Appointment Availability Survey Manual, including any alternative standards to the threshold rates of compliance for urgent or non-urgent appointments approved by the Department.
(iii) The plan's oversight procedures for ensuring compliance with the timely access standards set forth in subsection (c) of this Rule, including any periodic reporting requirements related to adherence of timely access standards by subcontracted plans in plan-to-plan contracts.
(B) Provider Appointment Availability Survey Report Forms.
(i) A plan shall submit the information and data obtained by the plan from conducting the Provider Appointment Availability Survey for each of the applicable Provider Survey Types set forth in the Provider Appointment Availability Survey Manual. A plan shall submit the information and data obtained by the plan from conducting the Provider Appointment Availability Survey on the report forms issued by the Department, form numbers 40-254 through 40-264, which are incorporated by reference and referred to collectively as “Provider Appointment Availability Survey Report Forms.” A plan shall use the version of each report form listed below noticed on the Department's website at www.dmhc.ca.gov, on or before May 1 of the measurement year.
a. Primary Care Providers Contact List Report Form (Form No. 40-254).
b. Non-Physician Mental Health Care Providers Contact List Report Form (Form No. 40-255).
c. Specialist Physicians Contact List Report Form (Form No. 40-256).
d. Psychiatrists Contact List Report Form (Form No. 40-257).
e. Ancillary Service Providers Contact List Report Form (Form No. 40-258).
f. Primary Care Providers Raw Data Report Form (Form No. 40-259).
g. Non-Physician Mental Health Care Providers Raw Data Report Form (Form No. 40-260).
h. Specialist Physicians Raw Data Report Form (Form No. 40-261).
i. Psychiatrists Raw Data Report Form (Form No. 40-262).
j. Ancillary Service Providers Raw Data Report Form (Form No. 40-263).
k. Results Report Form (Form No. 40-264), which includes the following:
1. Primary Care Providers Results Tab;
2. Non-Physician Mental Health Care Providers Results Tab;
3. Specialist Physicians Results Tab;
4. Psychiatrists Results Tab;
5. Ancillary Service Providers Results Tab;
6. Summary of Rates of Compliance Tab; and
7. Network by Provider Survey Type Tab.
(ii) A plan shall complete all Provider Appointment Availability Survey Report Forms as specified in the Provider Appointment Availability Survey Manual and Timely Access Submission Instruction Manual. For each Provider Survey Type applicable to a plan's network, a plan shall submit:
a. At least one Contact List Report Form containing all network providers specified in the Provider Appointment Availability Survey Manual. A plan shall populate the Contact List Report Form with the required network provider information as of the network capture date for the applicable measurement year.
b. At least one Raw Data Report Form, which shall contain each of the network providers the plan surveyed or attempted to survey, and the outcome or response to the Provider Appointment Availability Survey.
c. The results of the survey in Results Tabs, set forth in subsection (h)(6)(B)(i)k.1.-5. of this Rule, in a single Results Report Form. The Results Report Form is programmed by the Department to automatically calculate the rates of compliance using the formulas set forth on the Summary of Rates of Compliance Report Form and the Network by Provider Survey Type Report Form based on the information entered by the plan on each Results Tab set forth in subsection (h)(6)(B)(i)k.1.-5. of this Rule.
(C) Non-Compliance Information and Description of Corrective Action
(i) The Department issued filing number for the plan's efiling containing a description of the plan's procedure for identifying any incidents of non-compliance resulting in substantial harm to an enrollee, as defined in Civil Code section 3428, and patterns of non-compliance, as defined in subsection (b)(12) of this Rule. The policy and procedure shall include:
a. The plan's definition of an incident of non-compliance resulting in substantial harm to an enrollee, which at a minimum shall include the definition set forth in Civil Code section 3428;
b. The plan's definition of patterns of non-compliance, which at a minimum shall include the definitions set forth in subsection (b)(12) of this Rule; and
c. The plan's monitoring mechanism and the sources of information or data the plan uses to identify any patterns of non-compliance and incidents of non-compliance resulting in substantial harm to an enrollee.
(ii) Information describing whether the plan identified:
a. Any incidents of non-compliance resulting in substantial harm to an enrollee that occurred during the measurement year;
b. Any patterns of non-compliance that occurred during the measurement year; and
c. Any other evaluation or information regarding compliance that is required to be reported, including the requirements set forth in sections III.D and III.H. of the Timely Access Submission Instruction Manual and paragraphs 2, 67, 77, 78 and 85 of the Provider Appointment Availability Survey Manual.
(iii) A description of the identified non-compliance, set forth in subsection (h)(6)(C)(ii) of this Rule, and the plan's responsive investigation and determination.
(iv) A corrective action plan, which shall include the following information with respect to each identified incident of non-compliance resulting in substantial harm to an enrollee, pattern of non-compliance, and other compliance concerns required to be reported pursuant to subsection (h)(6)(ii) of this Rule:
a. The steps the plan has taken or intends to take with respect to each issue of non-compliance in order to address the non-compliance and to bring its network into compliance with the Knox-Keene Act; and
b. Any follow-up actions the plan has taken or intends to take to ensure compliance with the Knox-Keene Act and the plan's timeframe for completion of investigation, development of corrective action, implementation of corrective action, follow-up actions, and other requirements as outlined in subsection (h)(6)(C)(ii)-(iv) of this Rule.
(v) If the plan did not submit the information set forth in subsection (h)(6)(C)(ii)-(iv) of this Rule in a prior reporting year, the plan shall include the omitted information in the current reporting year.
(D) The Department issued filing number containing the plan's policies and procedures used for verifying network providers' advanced access programs, and a list of all provider groups and network providers utilizing advanced access appointment scheduling.
(E) The Department issued filing number containing a description of the implementation and use of triage, telemedicine, including the applicable telehealth modalities, and health information technology used by the plan and its network providers to provide timely access to care, as applicable.
(F) The Department issued filing number containing the plan's survey questions, survey methodology, and policies and procedures for administering and evaluating the results of the Enrollee Experience Survey and the Provider Satisfaction Survey. The plan shall include the results of the most recent annual Enrollee Experience Survey and Provider Satisfaction Survey, and a comparison with the results of the prior year's Enrollee Experience Survey and Provider Satisfaction Survey, including a discussion of the relative change in survey results.
(G) The quality assurance report including all information set forth in the Provider Appointment Availability Survey Manual.
(7) Annual Network Report. The Annual Network Report shall confirm the status of each of the plan's networks and enrollment, including the data categories set forth in subsections (a) and (g) of section 1367.035 of the Knox-Keene Act. The Annual Network Report shall consist of the items set forth in subsection (h)(7) and subsection (h)(8) of this Rule, for the applicable measurement year. The plan shall submit the items described in subsection (h)(7) within the Department's report forms in the manner described in subsection (h)(7)(B) of this Rule and in the Annual Network Submission Instruction Manual, which is hereby incorporated by reference. A plan shall use the version of the Annual Network Submission Instruction Manual noticed on the Department's website at www.dmhc.ca.gov, on or before November 1 of the calendar year prior to the reporting year.
(A) The Annual Network Report shall include the following information and data, in the format approved by the Department set forth in subsection (h)(7)(B) of this Rule and incorporated documents:
(i) The plan's enrollment in each network and product line, on a ZIP Code and county basis.
(ii) The network service area of each network, on a ZIP Code and county basis.
(iii) A complete list of all network providers within each network.
(iv) All grievances regarding network adequacy and timely access compliance received for each network during the measurement year described in subsection (b)(4)(A) of this Rule.
(B) Annual Network Report Forms. A plan shall submit the network information and data set forth in subsection (h)(7) of this Rule in accordance with the Annual Network Submission Instruction Manual. A plan shall use and submit only the following report forms issued by the Department, form numbers 40-265 through 40-272, which are incorporated by reference and referred to collectively as “Annual Network Report Forms”. A plan shall use the version of each report form listed below noticed on the Department's website at www.dmhc.ca.gov, on or before November 1 of the calendar year prior to the reporting year.
(i) Network Service Area and Enrollment Report Form (Form No. 40-265).
(ii) PCP and PCP Non-Physician Medical Practitioner Report Form (Form No. 40-266).
(iii) Specialist and Specialist Non-Physician Medical Practitioner Report Form (Form No. 40-267).
(iv) Mental Health Professional and Mental Health Facility Report Form (Form No. 40-268).
(v) Other Outpatient Provider Report Form (Form No. 40-269).
(vi) Hospital and Clinic Report Form (Form No. 40-270).
(vii) Telehealth Report Form (Form No. 40-271).
(viii) Timely Access and Network Adequacy Grievance Report Form (Form No. 40-272).
(C) A plan required to submit data in accordance with subsection (a)(4) of section 1371.31 of the Knox-Keene Act, shall use and submit only the report form issued by the Department for the submission of the required data, which is incorporated by reference and referred to as “Out-of-Network Payment Report Form” (Form No. 40-273) (October 27, 2022). A plan shall submit this data in accordance with the Annual Network Submission Instruction Manual. The plan shall report data required for the Out-of-Network Payment Report Form in accordance with the measurement year described in subsection (b)(4)(A) of this Rule.
(D) A plan required to submit data in accordance with subsection (d) of section 1374.141 of the Knox-Keene Act, shall use and submit only the report form issued by the Department for the submission of the required data, which is incorporated by reference and referred to as “Third-Party Corporate Telehealth Provider Report Form” (Form No. 40-274). A plan shall use the version of this report form noticed on the Department's website at www.dmhc.ca.gov, on or before November 1 of the calendar year prior to the reporting year. The plan shall report data required for the Third-Party Corporate Telehealth Provider Report Form in accordance with the data capture timeframes described in the report form instructions for this form.
(8) Network Access Profile. Before submission of the report forms set forth in section (h)(6) and (h)(7) of this Rule, the plan shall identify a health plan contact, complete or update the network access profile in the Department's web portal, so that it contains current information and data as of the network capture date for each applicable measurement year, as defined in subsection (b)(4)(A)-(B) of this Rule. The plan shall identify each network by its network name and network identifier, and describe each network identified pursuant to the requirements in this subsection and in the Annual Network Submission Instruction Manual. Prior to submission, the plan shall affirm the accuracy of the information and data, as described in subsection (h)(2) of this Rule. The plan shall submit the network access profile data as follows:
(A) The plan shall update the network access profile each year before submitting the reports to reflect changes to the reported networks as of the network capture date.
(B) Within the network access profile, the plan shall identify the network name and Department-assigned network identifier for each reported network. To the extent a plan has removed, added, or changed a reported network since the prior measurement year, the plan shall identify the appropriate amendment or notice of material modification of the plan's license, consistent with section 1352 of the Knox-Keene Act and related regulations.
(C) Within the network access profile, for each network the plan shall identify:
(i) The product lines that use the network;
(ii) The network service area; and
(iii) The source of network providers, including:
a. Whether the plan directly employs or contracts with network providers, in accordance with subsections (b)(10)(B)(i)-(iii) of this Rule;
b. Whether the plan serves as a primary plan or subcontracted plan for the network;
c. If the plan is a primary plan, the subcontracted plan networks that contribute network providers through plan-to-plan contracts, and any delegation of plan functions to those subcontracted plans, as applicable; and
d. If the plan serves as a subcontracted plan, the networks to which the plan contributes network providers through a plan-to-plan contract.
(D) Within the Annual Network Submission Instruction Manual and the Department's web portal, the Department shall set forth standardized terminology the plan shall use to submit data in the report forms. The plan shall report the required data within the report forms either by using the standardized terminology when reporting the information listed in subsections (h)(8)(D)(i)-(x) of this Rule, or by connecting the plan's own terminology to the standardized terminology, as available, via the crosswalk tables provided by the Department within the Department's web portal. Such areas of standardized terminology shall include the following:
(i) Hospital and other inpatient facility names. The plan shall report hospital and other inpatient facility names using the name on record with the California Department of Health Care Access and Information (HCAI), available at hcai.ca.gov, as of the network capture date. The Department shall make available annually a standardized list of hospital names within its web portal, based on the most recent data obtained from HCAI.
(ii) Product line categories.
(iii) Provider types. The plan shall report physician specialty type, non-physician medical practitioner specialty type, mental health professional specialty type, other outpatient provider type, hospital and other inpatient facility type, clinic type, and mental health facility type, according to the standardized terminology. Plans shall report physician specialties according to the network provider's primary specialty practice areas and plan credentialing. The plan shall identify the physician using the Department's standardized terminology, consistent with the physician specialty and subspecialty designations recognized by the American Board of Medical Specialties and the Knox-Keene Act. Non-physician medical practitioner specialty designations shall be based on the areas of specialization available through the appropriate licensing boards, as applicable.
(iv) Provider languages spoken.
(v) Provider group names. The plan shall report provider group names using the business name registered with the Secretary of State, the name on file with the Department for capitated provider groups, or the name on file with the Department for risk-bearing organizations that file information with the Department pursuant to Rule 1300.75.4.2, as applicable. The Department shall make available annually a standardized list of provider group names within the Department's web portal, based on filings with the Department and the Secretary of State. Each provider group reported by the plan shall match the most recent list on the Department's web portal. If the provider group is not listed on the Department's standardized list, the plan shall report the provider group using a name that is reported consistent within this subsection.
(vi) Type of license or certificate. The standardized terminology shall be consistent with one or more of the following sources: the Department of Consumer Affairs, the California Board of Registered Nursing, the Medical Board of California, the Osteopathic Medical Board of California, the National Plan and Provider Enumeration System taxonomy, or departments within California Health and Human Services Agency, including the Department of Health Care Services.
(vii) ZIP Code and county. The Department shall make available annually in its web portal a list of ZIP Codes and counties for the State of California, issued by the USPS. Each ZIP Code and county combination reported by the plan within California shall match the USPS list of ZIP Codes posted on the Department's web portal.
(viii) California license number and National Provider Identifier (NPI). The plan shall report NPI using the active identifier for that provider published on the National Plan and Provider Enumeration System (NPPES), NPI Registry, available at npiregistry.cms.hhs.gov, as of the network capture date. The plan shall report the California license using the active license number published by the Department of Consumer Affairs, available at www.dca.ca.gov, as of the network capture date. The Department shall make available annually, within its web portal, a list of active California license numbers for physicians updated based on the network capture date, derived from the Department of Consumer Affairs (www.dca.ca.gov). The Department shall make available annually in its web portal a list of de-activated NPIs, updated based on the network capture date, derived from the NPPES, NPI registry.
(ix) Grievance field values. The plan shall report information related to timely access and network adequacy grievances, as set forth in section 1367.035(a)(6) of the Knox-Keene Act.
(x) Telehealth location and modality. The plan shall report the modality by which telehealth is delivered and the location where the patient may receive telehealth services.
(9) Nothing in this section shall prohibit the Department from reviewing the information and data submitted pursuant to subsection (h) of this Rule for completeness or accurate reporting, and preventing submission of information and data that is incomplete or does not conform to the requirements set forth in this subsection or within any incorporated documents within this subsection. Information and data that is erroneous or contrary to the plan's representations to the Department within the plan's submission, or in other approved or pending filings, assessments, or actions with the Department, may be omitted from the Department's review of the Timely Access Compliance Report or the Annual Network Report. The plan shall retain full responsibility for ensuring the accuracy of the information and data, as set forth and required by subsections (a)(3), (a)(5), (h)(2), (i), and (j) of this Rule.
(i) Determining Compliance and Non-Compliance.
(1) A network is non-compliant with the requirements of this Rule and the Knox-Keene Act, related to timely access and network adequacy, under any of the following circumstances:
(A) The plan's annual submission pursuant to subsection (h) of this Rule does not demonstrate the plan has met network adequacy for a network service area;
(B) The results of the plan's Provider Appointment Availability Survey indicate a pattern of non-compliance, as described in subsection (b)(12)(A) of this Rule, was identified during a measurement year;
(C) The Department identified a pattern of non-compliance, as described in subsection (b)(12)(B) of this Rule;
(D) The plan failed to report timely, accurate, or complete information and data demonstrating network adequacy or timely access for a network service area.
(2) If the plan contends that the Department's finding of a violation of the Knox-Keene Act made during the review of the information submitted pursuant to this section was made as a result of the plan's failure to submit timely, accurate, or complete information in the reports set forth in subsections (h)(6)(B), (h)(7), and (h)(8) of this Rule, and not due to an actual failure of the plan to meet network adequacy requirements or time-elapsed standards set forth in subsection (c) of this Rule, the plan shall demonstrate that the Department's finding was due only to the plan's failure to submit timely, complete, or accurate information.
(3) The Department may find the plan is non-compliant with the requirements of subsection (c) of this Rule where the plan failed to provide timely access to health care services. When evaluating compliance with the standards set forth in subsection (c) of this Rule, the Department may focus more upon patterns of non-compliance rather than isolated episodes of non-compliance.
(4) The Department may consider all relevant factors when evaluating the severity and extent of non-compliance, including:
(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, failing to maintain an adequate number or type of network providers necessary to deliver timely and appropriate care, or misreporting network providers who are available to deliver covered services;
(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, network adequacy or data reporting deficiencies and to bring its network into compliance;
(C) The failure of a plan to follow the requirements of this section when submitting the annual reports set forth in subsection (h);
(D) 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, including the population served;
(E) The nature and extent to which a single instance of non-compliance results in, or contributes to, substantial harm including serious injury or damages to an enrollee;
(F) The plan's failure to monitor its network to ensure network adequacy, or to ensure network capacity and availability to meet the standards set forth under subsection (c);
(G) The nature and extent to which a single instance of non-compliance or a pattern of non-compliance results from the plan's failure to identify and address areas of network adequacy noncompliance in a manner prescribed under the Knox-Keene Act;
(H) The number of relevant network providers in the region, whether providers of the relevant health care services are otherwise available in the region, and a health plan's demonstration of its actions to bring the relevant providers into the network as network providers; and
(I) Whether the plan's non-compliance involves the same or similar enrollee cultural, demographic, or health circumstances.
(5) The Department may take enforcement action against a plan for any finding of non-compliance pursuant to this section.
(A) If a finding was made as a result of the plan's failure to submit complete or accurate information in the reports set forth in subsections (h)(6)(B), (h)(7), and (h)(8) of this Rule, the Department may take enforcement action for the plan's failure to submit complete or accurate network information.
(B) Prior to taking enforcement action, the Department may provide the plan with an opportunity to respond to the Department's findings of non-compliance, and present a corrective action plan, as applicable.
(i) A plan shall demonstrate it has implemented corrective action through appropriate staffing or other resources needed to bring itself into compliance with the reporting requirements within this section.
(ii) The Department may take enforcement action if the plan's failure to submit timely, complete or accurate information prevented the Department from reviewing the Plan's annual submission for compliance.
(iii) The Department may take enforcement action if the plan's responsive information or corrective action plan does not timely or sufficiently address the findings of non-compliance.
(iv) This subsection does not prevent the Department from taking immediate enforcement action related to the information submitted in subsections (h)(6), (h)(7), and (h)(8) of this Rule.
(j) Review and Enforcement.
Failure to comply with requirements of this section, including the failure to submit timely, complete, and accurate information and data within the Department's web portal or required annual reports, or failure to correct an identified deficiency, may constitute a basis for disciplinary or enforcement action against the plan. The Department may request additional information from the plan as deemed necessary to complete the review of required reports or information or to carry out and complete any enforcement action. The reporting plan shall be responsible for demonstrating compliance with this Rule and the Knox-Keene Act. The Director shall have the civil, criminal, and administrative remedies available under the Knox-Keene Act, including section 1394. Nothing in this section shall be construed as limiting the director's authority pursuant to Article 7 (commencing with section 1386) or Article 8 (commencing with section 1390) of the Knox-Keene Act.
(k) A plan shall not prevent, discourage, or discipline a network provider or employee for informing an enrollee or subscriber about the timely access standards.
(l) This rule applies to a licensed health care service plan that provides services to Medi-Cal beneficiaries. Nothing in this regulation is intended to alter the legal and contractual obligations for Medi-Cal managed care plans' reporting requirements to the Department of Health Care Services.

Credits

Note: Authority cited: Sections 1344, 1346, 1367.03, 1386 and 1394, 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 12-18-2009; operative 1-17-2010 (Register 2009, No. 51).
2. Amendment of section heading, section and Note filed 1-12-2022; operative 4-1-2022 (Register 2022, No. 2). (Transmission deadline specified in Government Code section 11346.4(b) extended 60 calendar days pursuant to Executive Order N-40-20. Filing deadline specified in Government Code section 11349.3(a) extended 60 calendar days pursuant to Executive Order N-40-20 and an additional 60 calendar days pursuant to Executive Order N-71-20.)
3. Amendment of subsections (d), (f)(1), (h)(1), (h)(3), (h)(4)(A)-(h)(4)(A)(i), (h)(4)(A)(iv)a. and (h)(4)(B) 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).
4. Amendment filed 4-25-2023; operative 4-25-2023. Submitted to OAL for filing and printing pursuant to Government Code section 11343.8. Exempt from the APA pursuant to Health and Safety Code section 1367.03, subsections (f)(3) and (f)(5) (Register 2023, No. 17).
5. New subsections (b)(22)-(b)(22)(H), amendment of subsections (d)(2)(A)(i), (d)(2)(B)(ii), (h)(6)(C), (h)(6)(C)(ii)b., new subsection (h)(6)(C)(ii)c. and amendment of subsections (h)(6)(C)(iv) and (h)(6)(C)(iv)b. filed 3-6-2024; operative 3-6-2024. Submitted to OAL for filing and printing only pursuant to pursuant to Government Code section 11343.4(b)(3). Exempt from the APA pursuant to Health and Safety Code section 1367.03, subsections (f)(3) and (f)(5) (Register 2024, No. 10).
This database is current through 4/26/24 Register 2024, No. 17.
Cal. Admin. Code tit. 28, § 1300.67.2.2, 28 CA ADC § 1300.67.2.2
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