Thursday, October 8, 2024
California Announces Settlement Agreements with L.A. Care Health Plan
Sacramento — California Department of Managed Health Care (DMHC) Director Mary Watanabe and Department of Health Care Services (DHCS) Director Michelle Baass issued the following statement on settlement agreements reached with Local Initiative Health Authority for Los Angeles County (L.A. Care Health Plan) requiring the plan to make improvements to their operations that ensure timely access to medically necessary health care services for all plan members, among other actions. This includes a $20 million settlement agreement between the plan and DHCS and a $35 million settlement agreement between the plan and DMHC, for a total of $55 million.
“The agreements reached by both Departments will have a real impact for L.A. Care Health Plan’s members and the delivery of health care services through the state’s Medi-Cal program.
“L.A. Care Health Plan will make meaningful improvements across the plan’s core functions to make sure the plan’s members receive appropriate medical care. This will include working with an outside consultant to take effective action and monitor improvements to the plan’s operations, including the 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. The plan will also make improvements to its oversight of contracted entities, such as hospitals, clinics, and other health care providers who deliver health care services, to ensure quality and timely care is provided to members.
“In addition to implementing these important corrective actions and paying a financial penalty of $27 million, L.A. Care Health Plan will contribute $28 million, the remainder of the $55 million settlement, into programs in Los Angeles County communities over the next three years. The funds will support health equity strategies, behavioral health efforts, and California Advancing and Innovating Medi-Cal (CalAIM), a statewide initiative focused on improving health outcomes for Medi-Cal members by integrating services, addressing social drivers of health, and improving care delivery.”
REAL IMPACT FOR HEALTH PLAN MEMBERS: L.A. Care Health Plan is the largest Medi-Cal plan in the state by number of members, with more than 2.5 million total members as of June 30, 2024. This includes 2,341,702 Medi-Cal members, 186,231 members enrolled in commercial coverage through the individual market, and 49,180 members enrolled in its In-Home Supportive Services (IHSS) line of business.
Under the settlement agreements with DHCS and DMHC, the plan will make contributions totaling $28 million (DHCS–$6.5 million and DMHC–$21.5 million) over a three-year period to benefit communities throughout Los Angeles County in the following areas: DHCS' Comprehensive Quality Strategy goals and guiding principles, which stress California’s commitment to health equity, member involvement, and accountability in all programs and initiatives and for all populations; CalAIM implementation; behavioral health; or a combination thereof.
WHAT HEALTH PLAN MEMBERS CAN DO: Both DMHC and DHCS have programs to help health plan members, including those with Medi-Cal coverage or commercial (private) coverage. DMHC encourages health plan members having trouble getting the care they need to first file a grievance, sometimes called an appeal, with their health plan. If the member does not agree with their health plan's response or the plan takes more than 30 days to fix the problem in non-urgent cases, the DMHC Help Center can work with the member and health plan to resolve the issue. If a health plan member is experiencing an urgent issue, they should contact the DMHC Help Center immediately at www.DMHC.ca.gov or 1-888-466-2219.
DHCS' Medi-Cal Managed Care and Mental Health Office of the Ombudsman works on behalf of plan members to help solve problems from a neutral standpoint and ensure that members receive all medically necessary covered services for which plans are contractually responsible. To contact the Ombudsman, email MMCDOmbudsmanOffice@dhcs.ca.gov or call 1-888-452-8609.
About DMHC:
The California Department of Managed Health Care (DMHC) protects the health care rights of 29.8 million Californians and ensures a stable health care delivery system. The DMHC Help Center has assisted 2.9 million Californians to 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.