Fall 2024
Message from the Director
One of my highest priorities is ensuring health plan members can access the health care services they need in a timely manner. This month, the DMHC and the Department of Health Care Services (DHCS) released a joint statement on settlement agreements with Local Initiative Health Authority for Los Angeles County (L.A. Care Health Plan). In addition to financial penalties, the plan will make improvements to their operations to ensure timely access to medically necessary health care services. In addition to implementing important corrective actions, L.A. Care Health Plan will make $28 million in contributions to improve the health care delivery system for some of the state's most vulnerable health care members in Los Angeles County.
The Department also released the results for the second phase of Behavioral Health Investigations (BHIs). The BHIs are providing insight into the challenges health plan members may face when accessing behavioral health care services. All violations found through the BHIs are referred to the Department’s Office of Enforcement to evaluate and take appropriate enforcement actions, which may include corrective actions and administrative penalties. You can find more information about health plan behavioral health coverage requirements in the Department’s fact sheet on Behavioral Health Care.
The DMHC published a new Transgender, Gender Diverse, or Intersex (TGI) Care page on the Department’s website to provide health plan members with helpful information and resources about their rights to gender-affirming care.
The DMHC Help Center is an important resource available to help health plan members facing issues with their health plan. The first step for a health plan member facing an issue is to reach out to their plan to file an appeal or grievance. If the health plan does not fix the issue within 30 days for non-urgent issues, the next step is to contact the DMHC Help Center for assistance at 1-888-466-2219 or www.DMHC.ca.gov. If the issue is urgent, the health plan member should contact the DMHC Help Center immediately.
Thank you for your support and continued interest in the DMHC.
Sincerely,
Mary Watanabe
Director
California Department of Managed Health Care
State Reaches $55 Million Settlement with L.A. Care Health Plan
The DMHC and DHCS announced both departments reached settlement agreements with L.A. Care Health Plan to ensure the plan’s members receive timely access to medically necessary health care services. Under the settlement agreements, L.A. Care Health Plan will pay $27 million in penalties and invest $28 million into Los Angeles County community programs supporting DHCS' Comprehensive Quality Strategies, California Advancing and Innovating Medi-Cal (CalAIM), or behavioral health.
L.A. Care Health Plan will also work with an outside consultant to monitor improvements and oversee corrective actions. The plan agreed to take corrective actions to improve its core functions including timely processing of requests to authorize care for members, handling of member grievances and appeals, and processing of provider disputes and payment of provider claims.
L.A. Care Health Plan is the state's largest Medi-Cal plan by number of members, with more than 2.5 million total members as of June 30, 2024.
Resources for Gender Affirming Care
The DMHC created a page on the Department’s website dedicated to educating Californians on their health care rights and access to gender-affirming health care services. This online resource includes frequently asked questions on Transgender, Gender Diverse, or Intersex (TGI) care, the types of medically necessary gender-affirming services typically covered by a health plan, fact sheets on navigating your health plan, how to file a complaint or seek an Independent Medical Review (IMR) with the DMHC, and additional useful state and federal resources.
The Department encourages health plan members experiencing issues with accessing care to first contact their health plan. If the plan member is not satisfied with their health plan's response, the DMHC Help Center can work with the member and health plan to resolve the issue. The health plan member can contact the DMHC Help Center at www.DMHC.ca.gov or 1-888-466-2219.
Behavioral Health Investigations
The DMHC released the results from the second phase of Behavioral Health Investigations (BHIs) in June.
The Department’s BHIs assess whether health plan members have consistent access to medically necessary behavioral health services, help identify systemic changes that can be made to improve the delivery of care, and detect non-compliant practices or barriers to care in specific health plans that may lead to delays in access to care.
The Phase Two Summary Report provides a summary of Knox-Keene Act violations and other barriers to accessing behavioral health care services. The Department identified 10 separate Knox-Keene Act violations that in some instances applied to multiple health plans. Additionally, through document review, interviews with the health plans and their delegates, as well as interviews with plan members and providers, the Department identified seven separate barriers to care, several of which were identified as applying to multiple health plans. The violations found through the BHIs are referred to the Department’s Office of Enforcement to evaluate and take appropriate enforcement actions, which may include corrective actions and administrative penalties.
DMHC Reviews 2025 Health Plan Rate Filings
Under state law, proposed premium rate changes for individual and small group health plans must be filed with the DMHC. Actuaries perform an in-depth review of these proposed changes and ask health plans to demonstrate that proposed rate changes are supported by data, including underlying medical costs and trends. The DMHC does not have the authority to approve or deny rate increases; however, the Department’s rate review efforts hold health plans accountable through transparency, help ensure health plan members get value for their premium dollar and saves Californians money. To date, the DMHC’s review of premium rates has saved members over $296 million.
The DMHC reviewed 13 individual market rate filings with an effective date of January 1, 2025. This included 12 filings offered through Covered California, the state’s health care exchange. For the 13 individual market rate filings, the final rate increases ranged from 1.8% to 15.4%, with an average increase of 7.8% across all health plans. The rate filings and the final rates are available on the Department’s website.
The DMHC also reviewed 12 small group market rate filings with an effective date of January 1, 2025. For the 12 small group market rate filings, the final rate increases ranged from 0% to 16.8%, with an average increase of 7.2% across all health plans. The rate filings and final rates are available on the Department’s website.
Additionally, the DMHC reviewed 36 large group market filings from 22 health plans. Health plans with large group products are required to file specified information at least annually and 120 days before any change in methodology, factors or assumptions that would affect the rate paid by a large group market employer or contract holder. The DMHC reviewed the health plans’ methodology, factors and assumptions used to develop rates to determine whether they are unreasonable or not justified.
DMHC Releases 2023 Annual Report
The DMHC released the 2023 Annual Report over the Summer, highlighting the Department’s achievements for the year. The DMHC now protects the health care rights of nearly 30 million people in California and regulates the majority of health care coverage statewide, including 96% of commercial and public enrollment in state-regulated health plans.
To learn more about these achievements, select the image of the 2023 Annual Report or Infographic below:
DMHC Enforcement Actions
The DMHC’s Office of Enforcement takes action against health plans that violate the law. The primary goal of an enforcement action is to protect health plan members and change the health plan’s behavior to comply with the law. Below are recent enforcement actions taken against health plans.
The DMHC took enforcement actions against Blue Cross of California Partnership Plan, Inc. and Blue Cross of California (Anthem Blue Cross) for failing to address provider payment disputes in a timely manner. California law requires health plans to acknowledge and resolve payment disputes promptly and accurately from hospitals, doctors and other providers. In this case, the plans failed to acknowledge a total of 98,955 provider disputes within the required timeframes, and a total of 32,635 provider disputes were not resolved in a timely manner. The plans agreed to pay a total of $8.5 million and are taking correction actions to improve response times to provider disputes.
The DMHC took enforcement actions, including a total of $850,000 in fines, against Blue Cross of California Partnership Plan, Inc. and Anthem Blue Cross for illegally limiting the coverage of services to treat gender dysphoria for health plan members. Both plans must take corrective actions to comply with the law and revise guidelines to remove the barriers to care for health plan members diagnosed with gender dysphoria. Additionally, the plans completed audits of denials of requests for services related to gender dysphoria and offered members rereview of previous denials. Also, the plans will retrain clinical review staff and dedicate a full-time case manager to address the needs of health plan members diagnosed with gender dysphoria. Finally, Anthem Blue Cross will implement a program designed to assist LGBTQIA+ members with appropriate and inclusive access to care.
The Department took enforcement action against California Physicians' Service (Blue Shield of California), including a $250,000 fine, for illegally billing health plan members for contraceptive health care services. Under the law, health plans must cover contraceptive health care services for all members without imposing a deductible, coinsurance, copayment or any other cost-sharing requirement. During the DMHC’s investigation, Blue Shield of California conducted an audit and identified 334 other health plan members who were wrongfully charged a cost share related to covered contraceptive health care services between 2016 and 2019. The plan reimbursed the impacted members, including interest. The plan paid the fine, and made $228,254 in reimbursements, interest and penalty payments to 334 members who were incorrectly charged.
DMHC Award for Hiring and Recruitment
The DMHC was honored with the DEI Leadership Seal Silver-tier designation in 2024 by the State Bar of California’s DEI Leadership Seal program. This recognition underscores the DMHC’s commitment to advancing diversity, equity, inclusion and belonging within both the workplace and the legal profession. As a recipient of the DEI Leadership Seal, the DMHC has been featured on the State Bar's official website.
The DMHC values diversity at all levels of the organization and is committed to fostering an environment in which employees from a variety of backgrounds, cultures, and personal experiences are welcomed and can thrive. The DMHC believes the diversity of our employees and their unique ideas inspire innovative solutions to further our mission. Check out the DMHC Leadership Team and About DMHC to find out more about each Program area. If you're interested in seeing all DMHC job opportunities, you can find them on the CalCareers website.
DMHC Social Media Outreach Toolkit Available
The Department recently developed a social media outreach toolkit to promote awareness of the DMHC’s role in protecting the health care rights of Californians. The goal is to empower health plan members and educate them about the appeal process if they are denied medically necessary care.
The toolkit is a result of the Department’s recent award-winning social media outreach campaign. For the campaign, the DMHC worked with an outside vendor to conduct research on consumer awareness, and host statewide focus groups with health plan members, stakeholders, and DMHC staff. Using data from that research, the Department developed this toolkit featuring social media posts that can be shared by others to provide helpful resources to health plan members.
The toolkit provides sample social media posts and collateral in English and Spanish. A few of the social media graphics are provided below.
Regulation Update
Fertility Preservation
The purpose of this regulation package is to require health plans to cover fertility preservation services when a health plan member has or will undergo a treatment that could result in becoming infertile and follows passage of Senate Bill (SB) 600 (Portantino, 2019). Fertility preservation services include egg or sperm retrieval, embryo creation, gonadal tissue retrieval, and cryopreservation of the genetic material taken from the enrollee. The regulation will, among other things, specify how many retrievals of genetic material a health plan must cover, and how long a health plan must cover storage of genetic material. On February 27, 2024, the DMHC submitted the rulemaking package to the Office of Administrative Law (OAL) for the public notice of rulemaking action. The first public comment period ran from March 8, 2024 through April 23, 2024. The second comment period ran from October 2, 2024 through October 17, 2024.
Provider Directories
The purpose of this regulation is to codify and further specify the requirements of SB 137 (Hernandez, 2015) by updating and promulgating the requirements of the Uniform Provider Directory Standards and by enumerating and defining the scope of requirements for a provider directory or directories and the obligations of health plans regarding provider directories. The DMHC anticipates beginning formal rulemaking for this package in Fall 2024.
DMHC Help Center
The DMHC Help Center protects health plan member rights, resolves member complaints, and helps members navigate and understand their coverage ensuring access to health care services.
The DMHC encourages health plan members experiencing issues with their health plan to first file a grievance or appeal with their health plan. Common issues include getting timely access to care, receiving an inappropriate charge or bill, or a denial or delay in care or treatment. If the member does not agree with their health plan's response to the grievance or appeal, or the plan takes more than 30 days to fix the problem for non-urgent issues, the member should contact the DMHC Help Center. The DMHC Help Center will work with the member and health plan to resolve the issue. The health plan member can file a complaint with the DMHC Help Center at www.DMHC.ca.gov or 1-888-466-2219. If a health plan member is experiencing an urgent issue, they should contact the DMHC Help Center immediately.
If a health plan denies, changes or delays a request for medical services, denies payment for emergency treatment or refuses to cover experimental or investigational treatment, a health plan member can apply for an Independent Medical Review (IMR) through the DMHC Help Center. Independent providers will review the case, and the health plan must follow the IMR determination. Approximately 72% of health plan members who file an IMR with the DMHC receive their requested service or treatment from their health plan. For more information about the IMR process or to apply for an IMR, please visit www.DMHC.ca.gov.
DMHC Career Opportunities
The DMHC has many exciting career opportunities available and is committed to attracting, hiring, and retaining quality employees who can help fulfill the mission of the Department to protect consumers’ health care rights and ensure a stable health care delivery system. More information about careers with the DMHC is located on the CalCareers website and the DMHC website under career opportunities. We encourage you to see what the DMHC has to offer!
DMHC Web Banners
You can help the DMHC raise awareness about health plan members’ rights and the DMHC Help Center. The Department created the following web banners to help raise awareness of the DMHC Help Center.
If your organization is interested in hosting the DMHC web banners on your website, please visit the DMHC website or email stakeholder@dmhc.ca.gov. The web banners are also available in additional languages, including Spanish.;
About DMHC:
The DMHC protects the health care rights of more than 29.8 million Californians and ensures a stable health care delivery system. The DMHC Help Center has assisted approximately 2.9 million health plan members resolve complaints and issues with their health plan. The DMHC Help Center provides assistance in all languages and all services are free. For more information visit www.DMHC.ca.gov or call 1-888-466-2219.