The Department’s Timely Access to Non-Emergency Health Care Services Regulation (“Timely Access Regulation”) became effective January 17, 2010. The purpose of the Timely Access Regulation, Rule 1300.67.2.2, is to fully implement AB 2179 (Stats 2002) which enacted Health and Safety Code section 1367.03. Section 1367.03 directed the Department to adopt regulations to ensure enrollees access to necessary health care services in a timely manner. Specifically, Section 1367.03 instructed the Department to consider the following:
- Waiting times for appointments with physicians,
- Timeliness of care in an episode of illness, including timeliness of referrals and obtaining other services,
- Waiting time to speak to a physician, registered nurse or other qualified health care professional acting within the scope of his or her practice who is trained to screen or triage an enrollee who may need care.
Section 1367.03 directed the Department to consider the clinical appropriateness, the nature of the specialty, the urgency of the care needed, and other legal requirements in developing the standards.
The health plans licensed by the Department have until January 17, 2011 to fully implement the policies, procedures and systems necessary to comply with Rule 1300.67.2.2. In October 2010, health plans must submit a filing to demonstrate how the standards of Rule 1300.67.2.2 will be met. Each health plan must show that its provider network is large and varied enough to offer enrollees appointments that meet the following standards:
- The clinical appropriateness standard requires that enrollees be offered appointments for covered health care services within a time period appropriate for their condition.
- Quality assurance standards requiring that enrollees be offered appointments within the following time-elapsed standards:
- Within 48 hours of a request for an urgent care appointment for services that do not require prior authorization,
- Within 96 hours of a request for an urgent appointment for services that do require prior authorization,
- Within ten (10) business days of a request for non-urgent primary care appointments,
- Within fifteen (15) business days of a request for an appointment with a specialist,
- Within ten (10) business days of a request for an appointment with non-physician mental health care providers, and
- Within fifteen (15) business days of a request for a non-urgent appointment for ancillary services for the diagnosis or treatment of injury, illness, or other health condition.
- The applicable waiting time for an appointment may be shortened or extended as clinically appropriate in the opinion of a qualified health care professional acting within the scope of his or her practice consistent with professionally recognized standards of practice. If the waiting time is extended, it must be noted in the relevant record that a longer waiting time will not have a detrimental impact on the health of the enrollee.
- Plans must contract with adequate numbers of doctors and other health care providers in each geographic area to meet the clinical and time-elapsed standards for appointment waiting times.
- In areas with provider shortages, plans are not excused from their obligation to arrange for enrollees to receive timely care as necessary for their health condition. If timely appointments are not available in a particular area, a plan must refer enrollees to, or, in the case of a preferred provider network, assist enrollees in locating, available and accessible contracted providers in neighboring service areas consistent with patterns of practice for obtaining health care services in a timely manner appropriate for the enrollee’s needs.
The Timely Access Regulation also requires health care service plans to demonstrate compliance with the following:
- Provide or arrange for the provision of 24/7 telephone triage or screening services, as defined in Rule 1300.67.2.2 (b)(5), for patients to obtain timely assistance in determining the urgency of their condition, including a reasonable call back time (not more than 30 minutes). A plan may provide telephone triage through various methods, but all methods must ensure triage is performed by qualified health professionals and, if provided through contracted primary care physicians and mental health care providers, the plan must provide a back up triage line if contracted providers are unable to meet the 30-minute call back time.
- During normal business hours, the waiting time for an enrollee to speak by telephone with a plan customer service representative knowledgeable and competent regarding the enrollee’s questions and concerns shall not exceed ten minutes.
Beginning in March 2012, health plans must also file an annual compliance report. The annual compliance report will include compliance rates for each of the time-specific standards. Plans must monitor network compliance with the standards, and must investigate and correct deficiencies.
Specialized plans licensed by the Department are subject to the Timely Access Regulation but to a lesser extent than the full service health plans. For a list of the subsections applicable to the specialized plans, please see subsection (a) (2) of Rule 1300.67.2.2.
To read the full text of Timely Access Regulation, Article 5, Section 1367.03.
To submit questions to the Department Timely Access Regulation, contact firstname.lastname@example.org