Health Plan Monitoring and Reporting Requirements
The Knox-Keene Act requires health plans to maintain provider networks that are sufficient to ensure that all covered health care services are readily available to each enrollee consistent with good professional practice. In addition, section 1300.67.2.2 in title 28 of the California Code of Regulations requires health plans to monitor and maintain networks sufficient to provide enrollees access to covered health care services within specific time-elapsed standards.
Health plans must submit to the DMHC on March 31st of each year a Timely Access Compliance Report that includes certain information related to monitoring network access during the previous calendar year, pursuant to subsection (g)(2) of section 1300.67.2.2 of title 28 of the California Code of Regulations. Health plans are required to include in this report network rates of compliance for each time-elapsed standard during the previous calendar year.
In order for rates of compliance to be comparable across all health plans, Health and Safety Code section 1367.03, subsection (f)(3) (as amended by SB 964 in 2014) authorizes the DMHC, in consultation with stakeholders, to develop standardize methodologies that are mandatory for use by health plans in measuring compliance with time-elapsed standards. The DMHC's standardize methodology requires health plans to survey network providers to assess the timeframe for the provider's next available appointment. The results of this survey are used to calculate rate of compliance with the time-elapsed standards for each of the health plan's networks.
As part of the annual submission of its Timely Access Compliance Report to the DMHC, each health plan is required to attest to the accuracy and completeness of the information contained in the report. In accordance with Health and Safety Code section 1367.03, subsection (i), the DMHC reviews the information submitted in the Timely Access Compliance Report, makes recommendations for changes to further protect enrollees, and posts final findings in the annual Timely Access Report, set forth below.
The current Timely Access Compliance Report Instructions, Methodology, Survey Tools and Reporting Templates are available to health plans in the Resource tab of the Timely Access Reporting Web Portal. The All Plan Letter, setting forth requirements related to the Timely Access Compliance Report, are available in the All Plan Letters Webpage.