The California Department of Managed Health Care has fined three health plans owned by Centene a total of $1.7 million for failing to meet reporting rate standards for timely access of appointments. The company has more than 117,000 providers serving more than three million members throughout the state.
Plan members are entitled to timely health care appointments under the Knox-Keene Health Care Service Plan Act of 1975. Health plans must ensure their provider networks can offer appointments within specific timeframes and must provide primary care providers within 15 miles or 30 minutes from where members live or work. Health plans are required to conduct annual surveys of their provider networks to ensure compliance with the state’s timely access to care standards, and the results are reported to the department.
These three plans were fined for failing to report minimum compliance rates for certain networks: Health Net of California, $1.2 million; Human Affairs International of California (under Magellan Health). $300,000; and Health Net Community Solutions, $200,000.
The department’s website outlines its definition of timely care.
“Health plans must ensure their network of providers, including doctors, can provide health plan members an appointment within specific timeframes,” it said. “A qualified health care provider may extend the waiting time for an appointment if they determine a longer waiting time will not be harmful to the member’s health.”
Requirements vary by type of service:
- Prior authorization for urgent care not required by health plan, 48 hours
- Prior authorization for urgent care required by health plan, 96 hours
- Non-urgent appointment with primary care physician, 10 business days
- Non-urgent appointment with specialty care physician, 15 business days
- Mental health or substance use disorder follow-up appointment, 10 days from previous appointment
The law also requires 24/7 telephone access to the plan, and interpreter services must be provided.
“Ensuring health plan members have timely access to the health care they need is a top priority for the DMHC,” said Mary Watanabe, the department’s director. “Delays in finding timely appointments can be a barrier for patients seeking medically necessary care and can have negative impacts on health plan members.”
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