CALIFORNIA LAW REGARDNG PROVIDER NETWORK ADEQUACY AND TIMELY ACCESS TO CARE

The following is information about the laws that exist to ensure clients are able to access appropriate health care services within specified distances and timeframes.

California law requires plans to have adequate provider networks and to provide clients with timely access to care. This means there are limits on how long clients should have to travel to see their see healthcare providers and how long they have to wait to get health care appointments, as well as telephone advice.

Provider network adequacy requirements specify the following:

• In rural counties, consumers must have access to care that is within 60 miles or 90 minutes from their home.²
• In small counties, consumers must have access to care within 45 miles or 75 minutes from their home.³
• In large counties, consumers must have access to care within 15 miles or 30 minutes from their home.sup>4

Timely access to care requirements specify the following:

• Consumers with urgent appointment needs are entitled to receive access to care within 48 hours, unless pre-authorization is required.⁵
• Those who have urgent appointment needs that require pre-authorization should have access to care within 96 hours.⁶
• Those with non-urgent mental health appointment needs are entitled to receive care within 10 business days.⁷
• Health plans must provide telephone triage or screening 24 hours a day, seven days a week.⁸ Calls made to telephone triage or screening lines must be returned within 30 minutes by a qualified health professional.⁹

Health plans and health insurers are also required to publish and maintain online and printed provider directories with information about contracting providers who offer services to enrollees or insureds. Consumers who are having problems locating available therapists and gaining timely access to care should first contact their health plan. If the health plans do not promptly resolve these issues, consumers should contact the California Department of Managed Health Care’s (DMHC) Help Center.

Providers who have information pertaining to provider network or timely access issues may file a grievance with the DMHC via the provider complaint process. See Sara Jasper’s article titled, “Help is Available to Providers.

¹Knox-Keene Health Care Service Plan Act of 1975 at Cal. Health & Safety Code §1340 et seq.; Cal. Health and Safety Code §§1300.67.2.2, 1367.03, 1371.4
²https://www.dhcs.ca.gov/formsandpubs/Documents/FinalRuleNAStandards3-26-18.pdf p. 21
³Id.
⁴Id.
⁵Cal. Health and Safety Code §1300.67.2.2(c)(5)(A)
⁶Cal. Health and Safety Code §1300.67.2.2 (c)(5)G)
⁷Timely access to care information and chart: https://www.dmhc.ca.gov/HealthCareinCalifornia/YourHealthCareRights/TimelyAccesstoCare.aspx
⁸Cal. Health & Safety Code §1300.67.2.2(c)(8)
⁹Cal. Health & Safety Code §1371.4
¹⁰Cal. Health & Safety Code §1367.27 & Cal. Ins. Code §10133.15; For more information about the requirements under the provider directory laws see Sara Jasper’s article titled, “What Providers Need to Know about the Provider Directory Law”

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