DMHC "Timely Access" Regulations

On January 17, the Department of Managed Health Care (DMHC) promulgated "timely access" regulations that HMOs and Blue Shield and Blue Cross plans must comply with by January 17, 2011. Physicians are rightly concerned that these regulations impose unrealistic requirements for seeing patients or responding to phone calls within certain timeframes. Importantly, these regulations are imposed on health plans; DMHC cannot penalize physicians for failing to comply. However, to meet these requirements health plans will look to physicians for compliance.

The SBCMS and CMA are consequently working to ensure that health plans have adequate physician networks to provide access to care and that health plan compliance requirements are reasonable. The regulations specifically require providing: urgent care appointments within 48 hours if they do not require prior authorization and within 96 hours if prior authorization is required; non-urgent appointments for primary care within ten business days and for specialty care within fifteen business days; non-urgent appointments with a non-physician mental health care provider within ten business days; and non-urgent appointments for ancillary services for the diagnosis or treatment of injury, illness, or other health condition within fifteen business days.

The waiting times may be extended if the referring or treating physician determines and notes that a longer waiting time will not have a detrimental impact on the patient and comports with professionally recognized medical standards. Also, preventive care and periodic follow up care, including but not limited to, standing referrals to specialists for chronic conditions, periodic office visits to monitor and treat pregnancy, cardiac or mental health conditions, and laboratory and radiological monitoring for recurrence of disease, may be scheduled in advance consistent with professionally recognized standards of practice.

The regulations also require health plans to arrange for telephone triage or screening that is available 24 hours per day, 7 days per week, and the waiting time to speak with someone cannot exceed 30 minutes. The plan may arrange for this telephone screening/triage through the plan's provider network, and if an answering machine is employed the machine or staff must inform the caller of the length of wait for a return call from the provider, and how the caller may obtain urgent or emergency care. Also, if a contracted physician cannot meet these requirements, the health plan must arrange for a triage or screening service.

The legislation on which these regulations are based was adopted in 2002 to ensure that health plans have adequate physician networks. Draft regulations to implement the law have been proposed 12 times since then, with CMA promoting amendments to make the regulation reasonable to physicians. Adopted CMA amendments include:

• a provision that allows a patient's wait time to be extended if the physician has determined that delay will not have a detrimental impact on the patient's health;
• a "provider's bill of rights" that requires HMOs to provide physicians with advance notice (45 business days) of any contractual changes and the right to negotiate those changes or terminate the contract;
• a provision stating that these regulations do not create additional physician liability;
• a requirement that HMOs demonstrate that they have an adequate physician network (1 primary care physician for every 2,000 patients in each health plan product) before implementing the regulation, including providing a complete list of contracted physicians.

 As stated above, enforcement action for failing to meet these requirements can only be exerted on health plans. The SBCMS and CMA are working to ensure that health plans contract with sufficient numbers of physicians to meet the access requirements, and that contractual requirements they propose to physicians are reasonable. HMOs must demonstrate how they will comply with the regulations no later than October 17, 2010, so the SBCMS and CMA will be active addressing the above issues leading up to that date and will keep you informed of developments.

CMA will be holding a webinar on this topic on Wednesday, February 3, from 12:15-1:15 p.m. To register go to: https://www2.gotomeeting.com/register/117806539. For more details, visit CMA's Members Only Site at: www.cmanet.org and view CMA On-Call document #1005 "Access to Physicians".