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Timely Access to Health Care

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Background

Effective January 17, 2011, the California Department of Managed Health Care implemented regulations to ensure that HMO enrollees have access to necessary health care services in a timely manner. (Health and Safety Code 1367.03). Health plans licensed by the Department of Managed Health Care must have a provider network that is large enough and varied enough to offer enrollees appointments that are clinically appropriate and that meet the timetables below. As of March 2012, plans are also required to file an annual compliance report, including compliance rates for each of the time‐specific standards.

Timelines

Timelines may be shortened or increased if deemed clinically appropriate by a qualified health care professional. A statement that the increased wait time will not detrimentally affect the patient’s health must be documented in the enrollee’s record.

Dental Appointments

  • Urgent care appointment
  • Within 72 hours of request
  • Non‐urgent care appointment
  • Within 36 business days of request
  • Preventative care appointments
  • WWithin 40 business days of request

Medical Appointments

  • Urgent care appointment, not requiring prior authorization
  • Within 48 hours of request
  • Urgent care appointment, requiring prior authorization
  • Within 96 hours of request
  • Non‐urgent primary care appointment
  • Within 10 business days of request
  • Specialist appointment
  • Within 15 business days of request
  • Appointment with a non‐physician mental health care provider
  • Within 10 business days of request
  • Non‐urgent appointments for ancillary services for the diagnosis or treatment of injury, illness or other health condition (x‐rays, lab tests, etc.)
  • Within 15 business days of request

Telephone Support

  • Telephone triage or screening services to determine urgency of condition
  • Available 24 hours/day, 7 days/week, with a call back time of no longer than 30 minutes
  • Waiting time to speak to a customer service representative at an enrollees health plan
  • No longer than 10 minutes

Appeals

If denied timely access to care, beneficiaries should file a complaint with their health plan. Beneficiaries can also file a complaint with the Department of Managed Care: HMO Help Line (888) 466‐2219 [voice] or (877) 688‐9891 [TDD] or online at http://www.dmhc.ca.gov/FileaComplaint.aspx#.VADfzHfOt8G.

For More Information

California Department of Managed Health Care: http://www.hmohelp.ca.gov/
Disability Access:
https://www.dmhc.ca.gov/HealthCareLawsRights/HealthCareRights/DisabilityAccess.aspx#.VADaQ3fOt8E

Sample Timely Access to Care Complaint Letter

 Your Name: Address: City/State/Zip: Telephone: Email:

Health Plan: Membership Number: Medical Group Name: Medical Group Number:

Today’s Date:

The reason for my complaint is as follows:

The health problem associated with this complaint is:

I have received the following treatment for this health problem (if no treatment has been received, write “none”):

The following doctors, specialists, and other health professionals have treated me for this health problem:

I look forward to receiving a written reply from you within 5 business days.

Sincerely,

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