California to Announce New Rules for HMO Members

On Wednesday, the California Department of Managed Health Care (“CDMH”) is scheduled to roll out new regulations that limit HMO members’ wait times for an appointment with a physician or specialist, the Los Angeles Times reports. The rules stem from a 2002 state law that called for HMOs to provide faster access to medical care. Since the initial passage of the law, DMHC has been in negotiations with health plans, hospitals, physician groups and others to work out details of the regulations.

Officials say California will be the first state to limit wait times for HMO members. About 21 million state residents are enrolled in HMO plans. The regulations by the California Department of Managed Health Care, in the works for much of the last decade, will require that patients have access to a health care professional at all times.  The Regulations will require that patients be treated by HMO doctors within 10 business days of requesting an appointment, and by specialists within 15. Patients seeking urgent care that does not require prior authorization must be seen within 48 hours. In addition, telephone calls to doctors’ offices will have to be returned within 30 minutes, and physicians or other health professionals will have to be available 24 hours a day.

The regulations also include wait time requirements for HMOs that offer dental, mental health, vision care and other services.  Consumers enrolled in non-HMO plans will not be directly affected by the new rules.  HMOs will need to submit plans for meeting the requirements within nine months and will need to comply with the new rules within one year.

After January 2011, DMHC will have the authority to penalize non-compliant HMOs.  Consumers also will be able to notify the department about delays in HMO care (See Helfand, Los Angeles Times, 1/19)

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