In December, several organizations, including CSAP, signed onto a letter regarding health plans’ forced transitions of enrollees to in-network providers after health plans failures to arrange medically necessary mental health and substance use disorder treatment within timely access and/or geographic distance standards set forth in the Health and Safety Code.
The letter argued that a plan cannot force someone back in network once they have found care out of network unless that transition is both consistent with generally accepted standards of care and the necessary services are available in network on an ongoing basis within timely access standards.
The Department replied with an updated request for health plan information (RHPI) that includes some positive updates but, unfortunately, still contains a number of issues, the biggest concern being that the Department is not doing due diligence before accepting a health plan’s assertion that a transition meets the requirements above. (The DMHC only asks health plans to include “the clinical determination relied upon when concluding the transition to an in-network provider is within the generally acceptable standards of care.”)
The coalition to which CSAP belongs continues to correspond with the Department on this issue, in particular requesting that DMHC (1) make additional changes to the RHPI to require health plans to provide evidence that a transition is within the standard of care (rather than just asserting without evidence that is and making the enrollee disprove the plan’s assertion) and (2) educate all impacted DMHC staff and health plans regarding these changes. We also ask DMHC to re-review all pending complaints concerning enrollee access to care under SB 855.
DMHC has confirmed they are taking a second look at the previously closed cases to determine if further assessment of the complaints is necessary. You may view the most recent version of the RHPI addendum here. The relevant changes that were made as a result of reviewing the joint letter sent December 15, 2022 are highlighted.
We believe additional changes are necessary to the RHPI are necessary and as a follow-up to a meeting with senior DHMC staff on January 18 have sent a letter outlining the requests and the reasons behind them. You may view the letter here.
While we appreciate our engagement with DMHC staff and DMHC’s attempts to make corrections to its RHPI, CSAP and other organizations are requesting that DMHC make additional changes to the RHPI to ensure health plans are not unlawfully shifting their evidentiary burdens under SB 855 to enrollees and educate all impacted DMHC staff and health plans regarding these changes.