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, health plans are required to monitor and maintain networks sufficient to provide enrollees access to covered health care services within specific time-elapsed standards and to meet network adequacy requirements set forth within the Act.

On an annual basis, full service health plans and specialized plans that provide mental health services are required to report to the DMHC information regarding the plan's compliance with time-elapsed standards for appointments and with network adequacy requirements, as described in Health and Safety Code sections 1367.03 and 1367.035, and title 28 of the California Code of Regulations, section 1300.67.2.2, subsections (g)(2) and (g)(2)(G). In addition, health plans are required to submit data related to out-of-network payments made at contracted facilities, pursuant to Health and Safety Code section 1371.31 subsection (a)(4). The DMHC reviews the data submitted annually for compliance with the Knox-Keene Act and the rules contained in title 28 of the California Code of Regulations.

Timely Access Reporting Requirements

By March 31 of each year, health plans are required to submit to the DMHC a Timely Access Compliance Report that includes information related to monitoring network access and 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) authorizes the DMHC, in consultation with stakeholders, to develop standardized methodologies that are mandatory for use by health plans in measuring compliance with time-elapsed standards. The DMHC's standardized 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 a rate of compliance with the time-elapsed standards for each of the health plan's networks. 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.

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. All Plan Letters related to the Timely Access Compliance Report are available on the All Plan Letters Webpage.

Annual Network Reporting Requirements

By March 31 of each year, health plans are required to submit to the DMHC information confirming the status of each of the plan's networks and enrollment, including a complete list of the plan's contracted providers, hospitals and enrollees within each network. Health plans also must submit a timely access and network adequacy grievance report and an out-of-network payment report as applicable. The DMHC reviews the information submitted for compliance with network adequacy requirements within the Knox Keene Act, in accordance with Health and Safety Code section 1367.035 subsection (d) and supporting regulations.

Related Timely Access Links

Section 1367.03 of the California Health and Safety Code

Section 1300.67.2.2 in Title 28 of the California Code of Regulations

List of Licensed Health Plans