Report 2018-122 Recommendation 6 Responses

Report 2018-122: Department of Health Care Services: It Has Not Ensured That Medi-Cal Beneficiaries in Some Rural Counties Have Reasonable Access to Care (Release Date: August 2019)

Recommendation #6 To: Health Care Services, Department of

To obtain assurance that health plans throughout the State exhaust all of their reasonable options to meet the access requirements before requesting alternative access standards, DHCS should immediately require health plans to authorize out-of-network care if they do not demonstrate they have exhausted all of their reasonable options to meet the access requirements, unless the health plans can demonstrate that closer providers are demanding unreasonably high rates or have documented deficiencies in quality of care.

1-Year Agency Response

DHCS continues to disagree with the recommendation. Through the AAS validation process DHCS verifies the MCP's ability to demonstrate exhaustion of all reasonable contracting efforts. If MCPs are unable to demonstrate that they have exhausted all reasonable contracting efforts with a closer provider, DHCS denies that AAS request. MCPs that have denied AAS are considered to not be meeting access requirements and are placed under a corrective action plan (CAP). Through the CAP process, DHCS requires MCPs to authorize out-of-network access including the cost of transportation, initiate and document contracting efforts with out-of-network providers, and ensure that member services staff are providing members with accurate information on the availability of out-of-network services. Additionally, as required in Welfare and Institutions Code 14197.04, MCPs with approved AAS must assist requesting members in obtaining an appointment with an appropriate out of network (OON) core specialist including best efforts to establish a member-specific case agreement, or the MCP must arrange for an appointment with an in-network specialist. Further, DHCS reviews out of network requests as part of the quarterly monitoring process to monitor access concerns.

California State Auditor's Assessment of 1-Year Status: Resolved

DHCS has implemented specific procedures to ensure that health plans demonstrate their efforts to contract with health care providers prior to its approval of alternative access standards. Accordingly, we consider this recommendation resolved.

6-Month Agency Response

MCPs are contractually required to provide out-of-network access for medically necessary services. DHCS currently requires MCP reporting on out-of-network requests by county and provider specialty type. DHCS will compare the out-of-network requests with the MCP's approved AAS to see if there is a correlation. Trends identified by DHCS will be included in the quarterly monitoring process.

California State Auditor's Assessment of 6-Month Status: Will Not Implement

Although DHCS describes that health plans are contractually required to provide out-of-network access for medically necessary services, it does not address how it would handle situations in which the health plans are not able to demonstrate that they have exhausted all reasonable options for meeting the access requirements. Our recommendation specifies that DHCS should require those plans to authorize out-of-network care.

60-Day Agency Response

DHCS continues to disagree with this recommendation. DHCS does agree that MCPs must exhaust all of their reasonable options to contract with closer providers before an AAS is granted. However, DHCS already has existing processes in place to request supporting documentation for AAS and is further strengthening this process through a sampling and validation process.

California State Auditor's Assessment of 60-Day Status: Will Not Implement

Although DHCS references its processes for reviewing supporting documentation for requests for alternative access standards, it does not address how it would handle situations in which health plans are not able to demonstrate that they have exhausted all reasonable options for meeting the access requirements. Our recommendation specifies that DHCS should require those plans to authorize out-of-network care.

All Recommendations in 2018-122

Agency responses received are posted verbatim.