As required under the law, and in furtherance of its mission to protect consumers, the DMHC reviews a variety of health plan operations on an ongoing basis for compliance with the law.
The DMHC provides the tools health plans need to submit all of the appropriate filings and reports.
Timely Access Compliance & Annual Network Reporting
In accordance with Health and Safety Code section 1367.03, sub. (f)(2)-(3) and Title 28 California Code of Regulations, section 1300.67.2.2, sub. (h)(6)-(8), all reporting plans are required to annually submit the Timely Access Compliance Report and the Annual Network Report to the DMHC on May 1 of each year. All profile-only plans are required to annually submit to the DMHC network profile information detailing the plan's approved network names, product lines, network service area, enrollment status, and plan-to-plan contracts, pursuant to title 28 of the California Code of Regulations, section 1300.67.2.2, sub. (h).
Submit Timely Access Compliance
Report & Annual Network Report
Quarterly Grievance Report
In accordance with Title 28 California Code of Regulations section 1300.68, sub. (f), all health plans shall submit a quarterly report to the DMHC describing grievances that were or are pending and unresolved for 30 days or more. The report shall be prepared for the quarters ending March 31st, June 30th, September 30th and December 31st of each calendar year and is due to the DMHC within 30 days of the end of the reporting quarter.
Block Transfer Filings
Before the termination date of its contract with a provider group or a general acute care hospital, health care service plans must submit an enrollee Block Transfer Filing to the DMHC. The DMHC reviews these filings to ensure compliance with applicable statutory (Knox-Keene Act) and regulatory (California Code of Regulations title 28) requirements.
The DMHC’s review ensures (1) that the network remains adequate without the terminating provider group or hospital and (2) that the impacted enrollees are timely notified of the termination and informed of their rights. If the DMHC approves a Block Transfer Filing, the health plan may inform its enrollees of the termination and redirect the enrollees to the alternate providers.
To request a copy of a Block Transfer Filing already submitted to the DMHC, please complete a Public Records Act request.
Health Plans may submit Block Transfer Filings via the Block Transfer Web Portal.
Arbitration Decisions
Each health plan, which uses arbitration to settle disputes with its members must file with the DMHC a copy of any written arbitration decision. The filed copy must include the amount of the award, the reasons for the award and the names of the arbitrators. By law, the names of the plan, member, witnesses, attorneys, provider, plan employees and plan facilities are deleted from the copy filed with the DMHC. These redacted copies of the decisions are filed each quarter and every effort will be made to post them on this site within the following quarter and made available to the public.