Spring 2024
Message from the Director
May is Mental Health Awareness Month, a crucial time for the Department of Managed Health Care (DMHC) to focus on one of our biggest priorities, mental health and access to behavioral health care and treatment. The Department’s fact sheet on Behavioral Health Care is a great resource for health plan members looking for information on their rights to behavioral health care. It is important to know that health plans must provide coverage for all mental health treatment that is medically necessary. The DMHC is also raising mental health awareness through our social media channels all month long, and we encourage you to share those social media posts so more health plan members are aware of their rights and mental health resources.
Over the last year, the DMHC’s Transgender, Gender Diverse, or Intersex (TGI) Working Group (Working Group) met to discuss the development of a quality standard for patient experience and training curriculum to train health plan staff in direct contact with TGI enrollees in the delivery of health care services. The Working Group issued its final Transgender, Gender Diverse, Or Intersex Working Group Recommendations Report, which included recommendations for the training curriculum and future development of a quality standard. In addition, the report includes a summary of the barriers the TGI communities experience in accessing health care and important recommendations and best practices for the collection of Sexual Orientation, Gender Identity, Gender Expression, and Sexual Characteristics (SOGIESC) data. I am grateful for the Working Group members for their willingness to share their stories and their thoughtful recommendations for improving health care access for the TGI communities.
The DMHC also worked with other California Health and Human Services Agency (CalHHS) leaders to ensure Californians are aware of their rights to contraceptive care and access to contraception, including for minors. The Department issued an All Plan Letter reminding health plans regulated by DMHC of their legal obligation to cover over-the-counter FDA-approved contraceptives with no cost-sharing to members.
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
Mental Health Awareness Month
This Mental Health Awareness Month, the DMHC is stressing the importance of mental health and access to behavioral health resources for all Californians. Governor Gavin Newsom recently announced the launch of MentalHealth.ca.gov, a one-stop source for people in need of mental health support. The website also includes information about the state’s ongoing behavioral health transformation.
The California Health and Human Services Agency (CalHHS) Mental Health Resources for Youth Webpage provides tools for children, teenagers and young adults and also parents, families and friends. The webpage also includes information on new digital tools that offer free behavioral health services, including behavioral health coaching for parents, caregivers and children up to age 12. This resource also provides phone numbers and links to the Suicide & Crisis Lifeline, CalHOPE, Youth Crisis Line, LGBT Youth Talkline and more for people who need support.
The DMHC also offers resources to educate California health plan members on their health care rights involving behavioral health care, which includes mental health and substance use disorders. The Department developed the May Mental Health Awareness Month Social Media Toolkit that features social media posts that can be shared to educate health plan members on their behavioral health care rights. This toolkit includes the Department’s Know Your Health Care Rights on Behavioral Health Care fact sheet in English and Spanish, and reminds health plan members that under California law, all DMHC-regulated health plans are required to cover medically necessary treatment for mental health and substance use disorders. This fact sheet also includes information on health plan members right to receive behavioral health treatment in a timely manner.
DMHC Director Awarded for Work to Improve Access to Mental Health Care for Children and Youth
The Department is being recognized for its work to ensure California’s children and youth have access to mental health services. The California Mental Health Advocates for Children and Youth (CMHACY) recently presented DMHC Director Mary Watanabe the Policy/Legislative Leadership Award for having a powerful and positive impact on the lives of California’s children and youth.
“I am honored to receive this award,” said Director Watanabe. “The DMHC’s work to improve mental health parity and access to behavioral health services for children and youth is crucial in improving the overall health of all Californians.”
Director Watanabe was presented the award on May 17, 2024, by Marika Collins, Director of Public Policy and Advocacy at Didi Hirsch 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.
DMHC Director Mary Watanabe (left) with Marika Collins, Director of Public Policy and Advocacy at Didi Hirsch Mental Health Services.
DMHC Director Watanabe (second from left) with CMHACY Board Members.
Right to Access Contraceptive Care
Earlier this year, the DMHC joined other California Health and Human Services Agency (CalHHS) leaders in reminding health plan members that California law requires contraception access, including for minors.
A report authored by the UCLA School of Law Center for Reproductive Health, Law, and Policy, revealed a significant percentage of California pharmacies either required parental consent or entirely withheld emergency contraception from minors – a clear violation of California’s law. The Department issued an All Plan Letter reminding health plans regulated by the DMHC of their legal obligation to cover over-the-counter FDA-approved contraceptives with no cost-sharing to members.
More information and resources on reproductive health care can be found at abortion.ca.gov.
DMHC Fines Anthem Blue Cross for Delaying Reimbursements to Providers & Members
The DMHC took enforcement action against Blue Cross of California (Anthem Blue Cross) including a $690,000 fine for failing to timely reimburse providers and health plan members for services provided. The plan agreed to pay the fine and implement corrective actions.
Between June and December in 2021, the plan failed to timely reimburse the provider or health plan member after receipt of an Independent Medical Review (IMR) decision that overturned the plan’s initial denial of services to the health plan member. Health plan members have the right to appeal to the health plan’s regulator to request qualified medical experts review their plan’s denial of services and determine whether disputed health care services were improperly denied. Through an IMR health care professionals completely independent of the health plan review the appeal.
Health plan members can file a complaint or apply for an IMR with the DMHC Help Center at www.DMHC.ca.gov or 1-888-466-2219.
TGI Working Group Issues Final Recommendations
The DMHC’s Transgender, Gender Diverse, or Intersex (TGI) Working Group (Working Group) recently issued its final Transgender, Gender Diverse, Or Intersex Working Group Recommendations Report. The Working Group was tasked with developing a quality standard for patient experience to measure cultural competency related to the TGI community and recommending a trans-inclusive training curriculum to be used by health care plan staff who are in direct contact with health plan members in the delivery of health care services.
The DMHC established the TGI Working Group following the adoption of Senate Bill (SB) 923 (Wiener, 2022). The Working Group met nine times from April 2023 to February 2024 and conducted four listening sessions throughout the state to gather valuable insights from TGI communities. The resulting recommendations in the report aim to foster a health care environment that is equitable and high-quality while also being responsive to the diverse needs of members of TGI communities.
The DMHC and the California Department of Insurance (CDI) will consider the Working Group's recommendations in the development of guidance related to implementation of SB 923. All guidance to the plans must be issued no later than September 2024.
Regulation Update
Mental Health and Substance Use Disorder Coverage
The purpose of this regulation package is to address health 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 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. OAL approved the regulation package on January 12, 2024, and the regulation became effective April 1, 2024.
Fertility Preservation
The purpose of this regulation package is to require health plans to cover fertility preservation services when an enrollee has or will undergo a treatment that could result in the enrollee becoming infertile and follows passage of 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 OAL for the public notice of rulemaking action. The first public comment period ran from March 8, 2024 through April 23, 2024. The DMHC is in the process of reviewing the public comments received and anticipates a second comment period beginning in early summer of 2024.
DMHC Help Center
The DMHC Help Center educates consumers about their health care rights, resolves health plan member complaints against their health plan, helps health plan members navigate and understand their coverage and ensures access to appropriate 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 68% 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 exciting 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 consumers’ health care rights and the DMHC Help Center. 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 29.7 million Californians and ensures a stable health care delivery system. The Department has helped 2.8 million Californians resolve health plan problems through the Help Center. Information and assistance is available at www.DMHC.ca.gov or by calling 1-888-466-2219.