Health care coverage: timely access to care.

Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act a crime. Existing law provides for the regulation of health insurers by the Department of Insurance. Existing law requires a health care service plan or health insurer that provides or arranges for the provision of hospital or physician services to comply with specified timely access to care requirements, including ensuring that its network has adequate capacity and availability of licensed health care providers to offer enrollees and insureds appointments that meet specified timeframes. Existing law authorizes the department director to take enforcement action against health care plans that fail to comply with these provisions, including assessing administrative penalties. This bill would require a health care service plan or health insurer to incorporate timely access to care standards into its quality assurance systems and incorporate specified processes. The bill would authorize the Department of Managed Health Care to develop methodologies to demonstrate appointment wait time compliance and averages. The bill would authorize the Department of Managed Health Care and the Department of Insurance to take compliance or disciplinary action, review and adopt standards concerning the availability of health care to ensure enrollees and insureds have timely access to care, and make recommendations to the Legislature if the Department of Managed Health Care or the Department of Insurance finds that health care service plans or health insurers and providers have difficulty meeting the standards the departments develop. The bill would require the director to consider, as an aggravating factor when assessing administrative penalties, if harm to an enrollee has occurred as a result of plan noncompliance. The bill would clarify that the timely access to care provisions do not alter requirements or standards for Medi-Cal managed care plans, except as specified. The bill would also make technical and conforming changes. By imposing new requirements on health care service plans, the willful violation of which would be a crime, the bill would impose a state-mandated local program. The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement. This bill would provide that no reimbursement is required by this act for a specified reason.