Report 2023-115 Recommendation 15 Responses

Report 2023-115: Department of Health Care Services and Department of Managed Health Care: Children Enrolled in Medi-Cal Face Challenges in Accessing Behavioral Health Care (Release Date: November 2023)

Recommendation #15 To: Health Care Services, Department of

To ensure that Medi-Cal managed care plan members do not have to travel unreasonable times or distances to receive care, DHCS should develop a definition of what times and distances are reasonable for members to travel. In doing so, DHCS should consider both the total time or distance a member needs to travel, as well as how those times and distances compare to other plans' times and distances for the same provider type and ZIP code. Thereafter, when DHCS determines that plans' requests for alternative time and distance standards are not reasonable, it should not approve those alternative access standards, thereby requiring those plans to offer members out-of-network access until such time as the plans can provide reasonable travel times and distances to care.

Annual Follow-Up Agency Response From December 2025

DHCS remains on track with the corrective actions outlined in the previous update submitted to CSA on 11/27/2024:

DHCS is finalizing its approach to define and determine the reasonability of members' travel considering total time or distances compared to other plans for the same provider type and ZIP code.

As part of this approach, DHCS' policy will consider denying alternative access standards when travel time/distance is unreasonable and will require plans to offer out-of-network access to care until the plans provide reasonable time/distance to care as part of ANC 2025. To the extent possible, the policy will be aligned across managed care delivery systems and can be adopted for specialty behavioral health as well.

California State Auditor's Assessment of Annual Follow-Up Status: Pending

1-Year Agency Response

DHCS has begun analysis and is working on a project plan and approach to define and determine the reasonability of members' travel considering total time or distances compared to other plans for the same provider type and ZIP code.

As part of this approach, DHCS' policy will consider denying alternative access standards when travel time/distance is unreasonable and will require plans to offer out-of-network access to care until the plans provide reasonable time/distance to care. To the extent possible, the policy will be aligned across managed care delivery systems and can be adopted for specialty behavioral health as well.

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

6-Month Agency Response

No change from the previous update: DHCS has begun analysis and is working on a project plan and approach to determine reasonability. To the extent possible, the policy will be aligned across managed care delivery systems and can be adopted for specialty behavioral health as well.

California State Auditor's Assessment of 6-Month Status: Pending

60-Day Agency Response

DHCS has begun analysis and is working on a project plan and approach to determine reasonability. To the extent possible, the policy will be aligned across managed care delivery systems and can be adopted for specialty behavioral health as well.

California State Auditor's Assessment of 60-Day Status: Pending

All Recommendations in 2023-115

Agency responses received are posted verbatim.