Attorney Articles | Summary of Department of Managed Health Cares Consumer Provider Plan Agency Meeting

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Summary of Department of Managed Health Cares Consumer Provider Plan Agency Meeting

Insurance Update: Summary of Department of Managed Health Care's Consumer Provider Plan Agency Meeting.

 (October 23, 2015)
Sara Kashing, JD
Staff Attorney

DMHC’s Director, Shelley Rouillard, began the meeting by presenting attendees with the Department’s Strategic Plan for 2015 through 2019. The Department’s mission is to protect consumers’ health care rights and ensure a stable health care delivery system. The Department is working to carry out that mission by pursuing the following goals:

  1. Educate and assist California’s diverse health care consumers
  2. Cultivate a coordinated and sustainable health care marketplace
  3. Regulate fairly, efficiently, and effectively
  4. Foster a culture of excellence throughout the organization

The Department’s Strategic Plan can be viewed in its entirety at https://www. DMHCStrategicplan.pdf

The group identified the following priorities for future CPPA meetings.

  1. Mental health parity compliance, reporting, and enforcement
  2. Integration of medical and behavioral health
  3. Availability of, and reimbursement for, telehealth services
  4. Lack of mental health providers/network adequacy
  5. Lack of a consistent definition for medical necessity
  6. Inconsistent billing criteria and communication with providers
  7. Crisis care, stabilization and appropriate follow-up, including residential and mobile outreach and outpatient follow-up
  8. Challenges getting authorization for additional sessions deemed necessary by providers
  9. Coordinated and continuity of care for Medi-Cal enrollees

Elizabeth Spring, Senior Attorney with the Office of Plan Licensing, gave the group a mental health implementation update. 26 plans have submitted draft notices that will go out to the public regarding consumers’ rights based on parity laws and DMHC’s interpretation of those laws. The notices will go out to consumers beginning next year. Beginning in the second quarter of 2016, DMHC will be doing an on-site survey of the plans to better determine and potentially enforce parity laws. The Department has asked for feedback from providers regarding common parity issues that their clients face. CAMFT will work with Ms. Spring and her office to determine how our members can be involved in providing feedback about common parity issues.

Deborah Haddad, Senior Attorney with the Office of Plan Licensing, gave an update on Timely Access Reporting. A summary of health and mental health compliance with the timely access regulations for measurement year 2014 will be available by the end of the year. Improvements to compliance reporting are being made as a result of SB 964. Under SB 964, the Department is required to do the following:

  1. Develop standardized methodology for reporting timely access compliance
  2. Annually review compliance and post findings on website
  3. Annually review plan provider networks
  4. Determine a rate of compliance that will allow comparison across plans
  5. Separate reports for Medi-Cal, Individual/ Family products, and all other commercial products

The Annual Report Components for Timely Access Reporting include:

  • Plan policies & procedures
  • Rate of compliance with the time elapsed standards
  • Incidents of non-compliance that resulted in substantial harm or patterns of non-compliance
  • Advanced access
  • Description of triage, telemedicine, and health information technology
  • Enrollee/Provider satisfaction surveys
  • Provider network snapshot

Kacey Kamrin, Senior Attorney with the Office of Plan Licensing, gave a presentation on the Department’s oversight of network adequacy. The Knox-Keene Act requires that consumers have “reasonable” access to providers. The Department is always interested in receiving input from stakeholders (providers and consumers) regarding what is reasonable access to mental health care since the laws don’t provide a clear definition. SB 137 requires that standardized information be provided in directories, result in penalties to plans for providing misinformation to consumers, and requires plans to investigate reports of misinformation within 30 days. SB 137 will likely help move the ball on network adequacy issues.

The dates for the 2016 meeting of the Consumer Provider Plan Agency group have not yet been determined.

Sara Kashing, JD, is a staff attorney for CAMFT. Sara is available to answer member calls regarding legal, ethical, and licensure issues.