Spring 2023
Message from the Director
May is Mental Health Awareness Month and the Department of Managed Health Care (DMHC) is focused on raising awareness about the importance of mental health, and consumers’ health care rights to behavioral health care services and treatment. California law requires all commercial health plans to provide coverage for medically necessary treatment of mental health and substance use disorders. You can find more information about health plan behavioral health coverage requirements in the Department’s Know Your Health Care Rights on Behavioral Health Care fact sheet. The Department has been working to share this information through our social media channels all month long, and I encourage you to help us spread the word so more Californians are educated about the resources available to them.
Recently, the DMHC established the transgender, gender diverse, or intersex (TGI) working group and convened the first meeting in Sacramento last month. The TGI working group will develop quality standards and recommend a training curriculum to train health plan staff in direct contact with transgender, gender diverse or intersex enrollees in the delivery of health care services. I look forward to the outcomes of this working group to achieve more positive health care experiences and better inclusion for the TGI community.
With the recent end to the federal public health emergency, the DMHC has provided updated information in a consumer fact sheet about COVID-19 testing, vaccines and treatment. Enrollees can continue to access these COVID-19 services with no cost-sharing or prior authorization requirements. Additionally, the Department continues to provide guidance to health plans, and more information is provided further on in this newsletter.
The DMHC Help Center is an important resource available to help enrollees facing issues with their health plan, like accessing care, coverage or treatment denials, or wrongful billing. The first step for an enrollee facing an issue is to reach out to their health 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.HealthHelp.ca.gov. If the issue is urgent, the enrollee 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
Mental Health Awareness Month & Behavioral Health Resources
May is Mental Health Awareness Month and the DMHC is sharing information and resources to support the mental health and well-being of all Californians. It is important to reduce the stigma around mental health and ensure those who need help can access resources. The California Health and Human Services Agency (CalHHS) Mental Health Resources for Youth Webpage provides important information and tools for youth, families, schools and teachers. This resource includes phone numbers and links to hotlines like the Suicide Prevention Lifeline, CalHOPE, Youth Crisis Line, LGBT Youth Talkline and more for people needing immediate support during a crisis. Tips and resources are provided to help families recognize the warning signs of suicide, depression and anxiety, as well as guides to help parents and teachers talk about mental health.
The DMHC has also made resources available to help educate Californians on their health care rights about behavioral health care. The Department recently developed the May Mental Health Awareness Month Social Media Toolkit, an online resource that can be shared on social media to educate consumers about their behavioral health care rights. This resource includes the Department’s Know Your Health Care Rights on Behavioral Health Care fact sheet in both English and Spanish, and emphasizes that under California law, all commercial health plans are required to cover medically necessary treatment for mental health and substance use disorders.
Additionally, the DMHC’s Know Your Health Care Rights on Timely Access to Care fact sheet is available in English and Spanish, and includes important information about timely access to care standards. Under the timely access standards, health plans must provide non-urgent mental health appointments and follow-up appointments with non-physician mental health care or substance use disorder providers within 10 business days. A qualified health care provider may extend the waiting time for an appointment if they determine a longer waiting time will not be harmful to the enrollee’s health.
TGI Working Group
The DMHC established the transgender, gender diverse, or intersex (TGI) working group to help eliminate health care disparities for Californians in the TGI community following the adoption of Senate Bill (SB) 923 (Wiener, 2022). The department announced the members of the committee in late March, and convened the first meeting on April 12.
The purpose of the working group is to develop quality standards and recommend a training curriculum to train health plan staff in direct contact with transgender, gender diverse or intersex enrollees in the delivery of health care services.
The Committee members and additional information about meetings can be found on the TGI Health Care Quality Standards and Training Curriculum Working Group page of the DMHC’s website. All meetings are open to the public.
CalHHS Leaders Work to Protect Reproductive Care
Earlier this year, the DMHC joined with other California Health and Human Services Agency (CalHHS) leaders in commemorating the 50th Anniversary of the U.S. Supreme Court’s decision in Roe v. Wade. This landmark decision ensured reproductive health care was a right and not a privilege.
To ensure appropriate access to reproductive health care, the DMHC reminded California health plans about their responsibility to cover and provide access to emergency and urgent care services when enrollees are out of state. This includes when an enrollee needs emergency or urgent care while in another state that may restrict access to reproductive health care services, like abortion care. The Department also issued an All Plan Letter reminding health plans of California statute requiring coverage for the off-label use of prescription drugs, including, but not limited to, the use of Misoprostol for medication abortion.
For more information on resources, abortion.ca.gov includes information about legal abortion rights, where to find providers, how to pay for services, financial assistance and more.
DMHC Seeks Two Members for Financial Solvency Standards Board
The DMHC is seeking two dynamic and solution-oriented professionals to serve on the Financial Solvency Standards Board (FSSB).
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.
Individuals with training and experience in subject areas or fields such as medical and health care economics, accountancy, actuarial studies, investment banking, and management and administration in integrated and affiliated health care delivery systems are encouraged to apply.
For more information, please read the Board Member Solicitation and Job Description. Interested candidates must submit required documents by June 30, 2023.
Health Plans Must Assist Enrollees Impacted by Natural Disasters
Following several severe weather events earlier this year, the DMHC is reminding impacted Californians that health plans must ensure enrollees displaced by natural disasters, including floods, earthquakes and wildfires, continue to have appropriate access to medically necessary health care services. This could include speeding up approvals for care, replacing lost prescriptions and ID cards, or quickly arranging health care at other facilities if a hospital or doctor’s office is not available due to the disaster. Read the DMHC’s consumer-focused fact sheet in English and Spanish for more information about what health plans are required to do to help enrollees impacted by a natural disaster.
COVID-19 Resources
The DMHC has worked alongside federal, state and local partners, health plans, providers, consumer advocates and others to support the state’s response to COVID-19. Since the beginning of the pandemic, the Department has taken several actions including providing guidance to health plans through All Plan Letters. This included guidance to health plans regarding COVID-19 treatment, testing, and immunizations.
The DMHC continues to update a COVID-19 webpage located on the Department’s website to make it easy for the public and stakeholders to find information, resources and guidance. The Department also makes consumer-friendly fact sheets available with updated information as the pandemic has progressed and updated guidance and requirements were released. The DMHC has created a consumer fact sheet on COVID-19 Testing, Vaccines & Treatment in English and Spanish with information following the end of the federal public health emergency and state of emergency. DMHC-licensed health plans must continue to cover COVID-19 tests, vaccines and treatment with no health plan prior authorization or enrollee cost-sharing. Enrollee cost-sharing includes co-pays, co-insurance, deductibles or other enrollee out-of-pocket costs not including health plan premiums.
Departments throughout the state are also continuing to ensure Californians have the resources they need to stay safe and healthy. You can find additional state resources below to stay informed on the latest information and guidance regarding COVID-19.
Taking Enforcement Action to Protect Consumers
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 consumers 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 action against Local Initiative Health Authority for Los Angeles County (L.A. Care Health Plan) for deceptive enrollment tactics which resulted in a $300,000 fine. The DMHC opened an enforcement investigation into the plan following a whistleblower complaint alleging L.A. Care Health Plan representatives used misrepresentation, deception and other tactics during the enrollment process. The Department found the plan misled 21 of the plan’s enrollees during the enrollment process, including making untrue or misleading statements that left enrollees without coverage or paying for treatment they were told they wouldn’t have to pay for. The plan agreed to pay the fine and implement several corrective actions, including monthly monitoring of sales staff, revising policies and procedures for call scripts, conducting staff trainings and coaching with sales and marketing staff, increased call monitoring, and establishing an internal auditing process to comply with the law.
The DMHC also took enforcement action against Health Net of California, Inc. (Health Net) for failing to accurately pay $1.2 million in provider claims. The plan failed to properly reimburse thousands of claims to the plan’s providers which resulted in a $225,000 fine. California law requires health plans to timely reimburse provider claims and failing to do so can impact the financial stability of providers and the overall stability of the health care delivery system. The plan agreed to pay the fine and take corrective actions including remediating $1.2 million in payments to providers.
Regulation Update
Mental Health and Substance Use Disorder Coverage
The purpose of this regulation package is to address health care service plans prior authorization and utilization management requirements, as well as network adequacy for mental health and substance use disorder providers. The regulation follows the passage of SB 855 (Wiener, 2020), and will ensure health care service plans use the most recent criteria and guidelines developed by a nonprofit professional association for the relevant clinical specialty when conducting a utilization review of mental health and substance use disorder medical services requested by an enrollee or provider. The package was submitted to the Office of Administrative Law (OAL) on December 6, 2022, and noticed to the public on December 16, 2022. The initial 45-day comment period ended on January 30, 2023. The Department is currently revising the text based on comments received during the initial comment period and anticipates going out on a second 15-day comment period soon.
Average Contracted Rate – Inflation Adjustment
The purpose of this regulation is to address the application of the inflation adjustment to the average contracted rate health plans are currently paying to applicable out-of-network providers and to address the effective date of the inflation adjustment requirement. The package was submitted to OAL and noticed to the public on March 17, 2023. The initial 45-day comment period ended on May 1, 2023. The Department is currently reviewing the comments received during the initial comment period and anticipates going out on a second 15-day comment period soon.
DMHC Help Center
The DMHC Help Center educates consumers about their health care rights, resolves consumer complaints, helps consumers navigate and understand their coverage and ensures access to appropriate health care services.
The DMHC encourages health plan enrollees 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 enrollee 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 enrollee should contact the DMHC Help Center. The DMHC Help Center will work with the enrollee and health plan to resolve the issue. The health plan enrollee can file a complaint with the DMHC Help Center at www.HealthHelp.ca.gov or 1-888-466-2219. If a health plan enrollee 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 enrollee 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 68% of consumers 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.HealthHelp.ca.gov.
DMHC Career Opportunities
The DMHC is always seeking smart, talented and enthusiastic people to join our team. More information about exciting careers with the DMHC is located on the CalCareers website.
DMHC Web Banners
The DMHC created the following web banners to help raise consumer 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 28.4 million Californians and ensures a stable health care delivery system. The Department has helped 2.6 million Californians resolve health plan problems through the Help Center. Information and assistance is available at www.HealthHelp.ca.gov or by calling 1-888-466-2219.