Winter 2025
Message from the Director
The Department of Managed Health Care (DMHC) is focused on continuing to support the state’s response and recovery efforts from the wildfires in Southern California. The DMHC is continuing to monitor the situation with our state partners, and will take all necessary action to make sure impacted health plan members have continued access to needed health care services covered by their health plan.
The DMHC directed health plans to help members impacted by the fires and ensure continued access to all medically necessary health care services. Some examples of the help health plans must provide to impacted members include speeding up approvals for care, replacing lost prescriptions and ID cards, refilling prescriptions sooner, or quickly arranging health care at other facilities if a hospital or doctor’s office is not available due to the fires.
My heart goes out to all of those who have been affected. Understandably, the devastation caused by the fires has caused significant stress for many. Those in need of support can reach out to their health plan for mental health services. Additionally, CalHOPE is a state resource available that offers critical behavioral health crisis counseling programs and uses a public health approach focused on strength-based strategies to build resiliency and connecting people to the support they need. The CalHOPE Warm Line can be reached at 833-317-HOPE (4673) in English and 833-642-7696 in Spanish. The CalHOPE Warm Line is a 24/7 peer run hotline that provides free, confidential emotional support to Californians, including those impacted by the fires.
If a health plan member is having difficulty getting the health care services they need, they should first contact their health plan for assistance. Contact information for DMHC-licensed health plans operating in Los Angeles and Ventura counties is provided in this resource guide. If a health plan member has problems getting assistance from their health plan, they can contact the DMHC Help Center at www.DMHC.ca.gov or 1-888-466-2219 (TDD: 1-877-688-9891) for further assistance. The DMHC Help Center provides help in all languages, and all services are free.
Thank you for your support and continued interest in the DMHC.
Sincerely,
Mary Watanabe
Director
Health Plans Must Assist Members Impacted by Fires
Following the Governor proclaiming a state of emergency, the DMHC issued an All Plan Letter (APL) directing health plans to make sure plan members impacted by the wildfires in Southern California can continue to access all medically necessary health care services, including prescription drugs.
DMHC Wildfire Resources
The DMHC has developed the following resources to share information with health plan members impacted by the wildfires in Southern California.
- The DMHC published a resource guide to help impacted health plan members find information on how their health plan can help them. The guide also provides contact information for health plans operating in Los Angeles and Ventura counties.
- The DMHC fact sheet on assistance for members impacted by natural disasters is available in English and Spanish, and provides information on health plan requirements during natural disasters, including wildfires.
- The DMHC developed a social media toolkit to share helpful information with health plan members about how their health plan can help them. The toolkit materials are downloadable and shareable.
State Wildfire Resources
In coordination with local, state, and federal partners, California is working to help people impacted by the Los Angeles fires get access to needed resources. For more information and resources from state, local and federal government visit CA.gov/LAfires.
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. Some of the recent enforcement actions taken by the DMHC are highlighted below.
The Department took enforcement action against Blue Cross of California (Anthem Blue Cross) for failing to handle health plan member complaints, also known as grievances or appeals, in a timely manner. California law requires a health plan to acknowledge receipt of a standard grievance within five calendar days and resolve a standard grievance and send a written resolution to the member within 30 calendar days. In this case, Anthem Blue Cross sent 11,670 late grievance acknowledgement letters to health plan members and 4,049 late resolution letters between July 2020 through September 2022. In addition to paying the $3.5 million fine, the health plan stated it implemented improvements to its grievance and appeals process.
The Department took enforcement action against Spring Care, Inc. (Spring Health), including a $1 million fine, for offering health care services, specifically Employee Assistance Programs (EAPs), in California without a license. EAPs contract with employers to offer benefits to employees, which may include services for health, mental health, alcohol and/or substance abuse problems. Spring Health was operating as an unlicensed plan by arranging for member care with network providers while collecting a prepaid or periodic charge. Spring Health acknowledged their failure to comply with the law and agreed to pay the $1 million penalty. In addition, Spring Health worked with the DMHC to obtain a license so they can continue providing health care services to California-based employees legally.
The Department took enforcement action, including $500,000 in fines, against Anthem Blue Cross for failing to provide basic health care services and acknowledge complaints filed by a health plan member during cancer treatment. In this case, the plan failed to acknowledge and respond to a total of 17 grievances by the member, who called the plan repeatedly after it failed to cover basic health care services, including hospital-related costs for surgeries. Among those calls, the member contacted the plan 10 times when they learned the plan failed to authorize life-saving chemotherapy. The plan paid the $500,000 penalty, repaid providers over $20,000 in money owed plus interest, and took corrective action to improve communication with members filing grievances. In addition, the plan will provide training for staff to ensure grievances are correctly identified and out-of-network authorization processes are followed.
California’s Essential Health Benefits and Updating the Benchmark Plan
In collaboration with the Administration and the state legislature, the DMHC is reviewing the process to update California’s benchmark plan. The benchmark plan serves as the standard for Essential Health Benefits (EHBs) for individual and small group health plan contracts.
In June 2024, the DMHC hosted the first public meeting to discuss the process for updating the benchmark plan and to provide an opportunity for the public to provide comments about the benefits that should be considered for inclusion in the new benchmark plan.
The DMHC will hold another public meeting on January 28, 2025, to share the analysis and cost estimates. The public may provide comments about the benchmark plan or EHBs during this meeting. Visit the Department’s website for more information.
DMHC Releases Annual Drug Pricing Report
The Prescription Drug Cost Transparency Report for Measurement Year 2023 looks at the impact of the cost of prescription drugs on health plan premiums and compares this data across reporting years 2017 through 2023. Results show that health plan spending on prescription drugs has increased by $4.9 billion, or 56% since 2017. These increases underscore the importance of the Administration’s efforts to slow health care spending through the Office of Health Care Affordability (OHCA) and forthcoming proposals to further increase transparency in the pharmaceutical supply chain.
Health plans in the commercial market must annually report their prescription drug costs to the DMHC. The Department then prepares an annual report summarizing the findings and the impact of prescription drug costs on health care premiums. In developing the report, the DMHC considered the total volume of prescription drugs covered by health plans and the total cost paid by health plans for those drugs. The Department also analyzed how the 25 most frequently prescribed drugs, the 25 most costly drugs, and the 25 drugs with the highest year-over-year increase in total annual spending impacted health plan premiums.
DMHC Seeks Members for Financial Solvency Standards Board
The DMHC is seeking dynamic and solution-oriented professionals to serve on the Financial Solvency Standards Board (FSSB).
The FSSB meets quarterly to advise the Director on matters of financial solvency that affect the delivery of health care services. The purpose of the FSSB is to advise the Director on matters of financial solvency that affect the delivery of health care services, and to develop and recommend financial solvency requirements and standards relating to plan operations, plan-affiliate operations and transactions, plan provider contractual relationships, and provider-affiliate operations and transactions. Additionally, the FSSB periodically monitors and reports on the implementation and results of the financial solvency requirements and standards, and reviews proposed regulation changes.
For more information, please read the Board Member Solicitation and Job Description. Interested candidates must submit required documents by February 28, 2025.
DMHC Social Media Outreach Toolkits
The DMHC works to educate and inform health plan members about their rights and health plan requirements through social media outreach. The Department has developed social media toolkits to help raise awareness and inform the public about their health care rights. You can help the Department spread awareness by sharing these resources with your social media audience.
The DMHC currently has two social media toolkits available, in both English and Spanish. The first toolkit shares resources available for health plan members impacted by the wildfires in Southern California. The second toolkit promotes awareness about the rights health plan members have in DMHC-regulated plans, and provides information about the appeal process if a member is denied care.
DMHC Recognized with Awards in 2024
Policy/Legislative Leadership Award
The California Mental Health Advocates for Children and Youth (CMHACY) presented DMHC Director Mary Watanabe with the Policy/Legislative Leadership Award for the Department’s work to ensure California’s children and youth have access to mental health services.
CMHACY presents the Policy/Legislative Leadership Award to individuals who seize upon opportunities to build improvements in mental health care and who are undaunted by competing priorities and other challenges. The non-profit group, incorporated in 1984, is dedicated to promoting the mental health of children and youth and fostering effective mental health services within public and private agencies, schools, and institutions.
Hiring and Recruitment Award
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. Learn more about the Department and each Program area on the website. If you're interested in seeing all DMHC job opportunities, you can find them on the CalCareers website.
Social Media Award
The DMHC was awarded the Influence Award in Social Media Campaigns from the California Capital Chapter Public Relations Society of America. The award was for the DMHC’s 2024 Social Media Outreach Campaign to promote awareness about the Department’s role in protecting the health care rights of Californians, and to educate and empower health plan members about the appeal process if they are denied care. Learn more about the DMHC’s 2024 Social Media Outreach Campaign on the Department’s website.
New Year, New Laws
The Governor signed several bills in 2024 that directly impact the DMHC. The Department will continue working to implement these bills over the coming year. Below is an overview of some of these bills.
Medication Assisted Treatment – AB 1842 (Reyes)
AB 1842 (Reyes) requires health plans to cover at least one drug used in specified opioid use disorder treatment categories without prior authorization, step therapy or utilization review. This bill took effect on January 1, 2025.
Maternal Mental Health Screenings – AB 1936 (Cervantes)
AB 1936 (Cervantes) requires a health plan maternal mental health (MMH) program to provide at least one MMH screening during pregnancy, at least one additional screening during the first six weeks of the postpartum period and additional postpartum screenings when medically necessary and clinically appropriate in the treating provider’s judgment. This bill took effect on January 1, 2025.
Health Care Coverage – VEBA – AB 2063 (Maienschein)
AB 2063 (Maienschein) extends the repeal date of a pilot program that allows DMHC-approved providers to undertake risk-bearing arrangements with a Voluntary Employees’ Beneficiary Association (VEBA). The pilot program will be extended to December 31, 2027, and the bill’s sunset date is extended to January 1, 2030.
Group Health Care Coverage: Biomedical Industry – AB 2072 (Weber)
AB 2072 (Weber) extends the sunset date for current law allowing multiple employer welfare arrangements (MEWAs) to provide large group health care coverage to member employers in the biomedical industry for an additional four years to January 1, 2030.
PANDAS/PANS Coverage – AB 2105 (Lowenthal)
AB 2105 (Lowenthal) requires health plans to cover prophylaxis, diagnosis and treatment of Pediatric Acute-Onset Neuropsychiatric Syndrome (PANS) and Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS) and that is prescribed or ordered by the treating physician and surgeon and is medically necessary. This bill took effect January 1, 2025.
Postpartum Contraception– AB 2129 (Petrie-Norris)
AB 2129 (Petrie-Norris) requires a contract between a health plan and a health care provider to authorize the provider to bill separately for devices, implants or professional services associated with immediate postpartum contraception if childbirth takes place in a hospital or birthing center. This bill took effect on January 1, 2025.
Health Information – AB 2198 (Flora)
AB 2198 (Flora) requires the DMHC, beginning January 1, 2027, or when final federal rules are implemented, whichever occurs later, to require health plans to establish and maintain patient access application programming interfaces (API), provider access API, payer-to-payer API and prior authorization API.
Preventive Services Coverage & Cost Sharing – AB 2258 (Zbur)
AB 2258 (Zbur) prohibits group or individual health plan contracts from imposing cost-sharing for items and services necessary for providing covered preventive care. The bill also prohibits cost-sharing for office visits for preventive care services if the services are not billed separately from the office visit. This bill took effect on January 1, 2025.
MEWA Coverage – AB 2434 (Grayson)
AB 2434 (Grayson) authorizes an association with small employer members in the engineering, surveying or design industry to purchase large group health care coverage though a MEWA. The associate and the MEWA must register with the DMHC by June 1, 2025, and provide annual compliance filings. This bill will sunset on January 1, 2030.
Behavioral Health & Wellness Screenings – AB 2556 (Jackson)
AB 2556 (Jackson) requires a health plan to provide members with a written or electronic notice annually regarding behavioral health and wellness screenings for children and adolescents ages 8 to 18 years old. This bill took effect January 1, 2025.
FSSB Membership – AB 2767 (Santiago)
AB 2767 (Santiago) increases the number of Financial Solvency Standards Board (FSSB) members from eight to 11, including the Department’s Director. The bill adds two eligible categories that may be appointed by the DMHC Director: health care consumer advocates and individuals with training and experience in large group health insurance purchasing. This bill took effect January 1, 2025.
Sexual Assault Coverage – AB 2843 (Petrie-Norris)
AB 2843 (Petrie-Norris) requires full-service health plans to provide coverage for emergency room medical care and nine months of follow-up services for a health plan member who is treated after a rape or sexual assault without cost sharing. This bill takes effect July 1, 2025.
Human Milk– AB 3059 (Weber)
AB 3059 (Weber) includes medically necessary pasteurized donor human milk from a licensed tissue bank under the existing requirement for health plans to cover basic health care services. This bill took effect January 1, 2025.
DMHC Review of Records – AB 3221 (Pellerin)
AB 3221 (Pellerin) allows the DMHC to access digitally searchable, electronic formats of specified information during on-site medical surveys and inspections of health plans. The bill also clarifies the Department may take enforcement actions or pursue further investigations before initiating or completing a follow-up survey after an initial survey. This bill took effect January 1, 2025.
Claim Reimbursement – AB 3275 (Soria)
AB 3275 (Soria) changes the timeframes for reimbursing, contesting and denying claims for health care services from 30 and 45 working days to 30 calendar days for all complete claims. The bill increases the penalty on health plans for not automatically paying interest owed on a claim. Enrollee complaints about a delay or denial of claim payment would be treated as a grievance under the Knox-Keene Act. This bill takes effect January 1, 2026.
HIV Preexposure Prophylaxis & Postexposure Prophylaxis – SB 339 (Wiener)
SB 339 (Wiener) allows a pharmacist to dispense up to a 90-day course of preexposure prophylaxis (PrEP), or more under certain conditions. Health plans are required to cover and pay for PrEP and postexposure prophylaxis (PEP) furnished by a pharmacist, including the pharmacist’s services and related testing ordered by the pharmacist as specified under the bill. This bill went into effect February 6, 2024.
Fertility/Infertility Services Coverage – SB 729 (Menjivar)
SB 729 (Menjivar) requires large group health plans to provide coverage for diagnosis and treatment of infertility and fertility services and removes the coverage exclusion for in vitro fertilization (IVF). The bill requires small group health plans to offer such coverage. This bill takes effect July 1, 2025. CalPERS plans are delayed to July 1, 2027.
Utilization Review Requirements – SB 1120 (Becker)
SB 1120 (Becker) requires a health plan that uses artificial intelligence (AI), an algorithm or other software tools for utilization review or utilization management to ensure compliance with specified requirements, including that the tool be fairly and equitably applied. The bill also prohibits AI, algorithms or software tools from making decisions to deny, delay or modify medically necessary health care services, and requires adverse medical necessity decisions be made by a licensed physician or health care professional. This bill took effect January 1, 2025.
Emergency Medical Services Coverage – SB 1180 (Ashby)
SB 1180 (Ashby) requires health plans to establish a process to reimburse Emergency Medical Services (EMS) alternative programs, including services provided by a community paramedicine program, triage to alternative destination program, or mobile integrated health program. Health plans would be prohibited from charging enrollees more than the in-network cost sharing amount, and reimbursement amounts must not exceed the health plan’s usual and customary charges for the services. The bill takes effect July 1, 2025.
MH/SUD Treatment – SB 1320 (Wahab)
SB 1320 (Wahab) requires health plans to establish a process to reimburse providers for mental health and substance use disorder (MH/SUD) treatment services that are integrated with primary care services. This bill takes effect July 1, 2025.
Health Care Omnibus – SB 1511 (Health Committee)
SB 1511 amends the Knox-Keene Act to renumber a duplicate section and clarify that reference to a “group” in the Knox-Keene Act does not include a Medi-Cal managed care contract between a health plan and DHCS. This bill took effect January 1, 2025.
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. The third comment period started on January 13, 2025, and will end on January 28, 2025.
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 submitted the rulemaking package to OAL for public notice of rulemaking action on December 31, 2024. The public comment period is open from January 10, 2025, through February 24, 2025.
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 complaint, sometimes called 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 their complaint or the plan takes more than 30 days to fix the problem for non-urgent issues, the member can 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 the health plan member has an urgent grievance, they do not need to file with their health plan first. A health plan member with an urgent grievance can file directly with the DMHC Help Center.
If a health plan denies, changes or delays a request for health care treatment or 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 treatment or service 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.