The California Department of Managed Health Care (DMHC) recently finalized regulations that require HMO patients to be seen in a timely manner. The primary intent of these regulations and the underlying legislation is to require HMOs to ensure that their networks of providers have the capacity and availability to provide care to enrollees within certain timeframes for various levels of care.

As you may recall, CMA supported the underlying legislation, AB 2179, which was signed into law in 2002 and directed the state to develop regulations to ensure that HMO enrollees have timely access to health care services. CMA supported that legislation because it promised to improve the adequacy of provider networks. The regulatory effort to implement AB 2179 has taken eight years to complete, during which time we have seen at least a dozen proposals from DMHC.

Over the last year, CMA obtained several concessions from DMHC to address our major concerns with these regulations, such as:

• a provision that allows a patient’s wait time to be extended if the physician has determined that delay will not have a detrimental impact on the patient’s health
• a “provider’s bill of rights” that requires HMOs to provide physicians with advance notice of any contractual changes and the right to negotiate those changes.
• a provision stating that these regulations do not create additional physician liability.
• a requirement that HMOs demonstrate they have an adequate physician network before implementing the regulation.

"We are hopeful that these new regulations will work as intended," says CMA President Brennan Cassidy, M.D. "As doctors, our No. 1 priority is our patients. We want to be sure that HMOs meet these requirements without forcing doctors to shorten patient visits or meet unrealistic quotas that would comprise the quality of care."

Both the regulations and the underlying law impose requirements on HMOs, not physicians. However, to comply with the regulations, HMOs will very likely pass on these requirements contractually to physicians and other providers. This in turn may require modification of existing physician office procedures to comply with the additional scheduling or reporting requirements.

As part of the regulations, HMOs are required to meet the minimum physician-to-patient ratios established in the Knox-Keene Act. The Knox Keene Act already requires HMOs to maintain provider networks with certain ratios of physicians to enrollees, but very little recent information on network adequacy is available because the state does not regularly monitor compliance.

HMOs still need to develop the contractual amendments necessary to comply with these regulations, so there will not be a full picture of what physicians need to know regarding contracting or implementation for some time. HMOs have until October 17, 2010, to file a compliance plan with DMHC, by which point we should have a more fully developed picture of what physicians need to know and do. CMA will be in contact with HMOs during this process to provide physician perspective. HMOs must fully comply with the regulations by January 17, 2011.

For more information on these regulations, see the newly updated On-Call document #1005, "Access to Physicians." On-Call documents are available free to members. Nonmembers can purchase On-Call documents for $2 per page in the CMA bookstore.

CMA has also scheduled two webinars on this topic with Armand Feliciano, CMA Associate Director of Medical and Regulatory Policy. The first webinar is Thursday, January 28 from 12:15-1:15 p.m., and the second Wednesday, February 3 from 12:15-1:15 p.m. Registration is free to members, but space is limited, so reserve your space today. If you are unable to participate in the live webinar, it will be available for on-demand viewing beginning the following day.

Contact: Member Help Line, 800/786-4CMA or memberservice@cmanet.org.