America’s health care law, the Affordable Care Act, turns one year old on March 23. That’s good news for California one-year-olds, and seven-year-olds, and lots of other California kids.

California leaders have worked hard to build a track record of success on health care reform, especially the portions which deal with children’s health issues. As a result, roughly four million children who would otherwise be uninsured can see a doctor when they are sick or injured, get the preventive care they need to stay healthy and can’t be denied health coverage because of a pre-existing health condition.

The California Department of Managed Health Care will continue to make sure that the Affordable Care Act can deliver even bigger wins for kids in the coming years. The law authorizes new insurance marketplaces or “exchanges,” to make private insurance work better. Exchange plans can make pediatrician-recommended care available to kids through private insurance, and subsidies can make care more affordable for children in middle-class families. The law also authorizes improvements to Medi-Cal that can make health care a reality for millions more children who are uninsured today.

The Affordable Care Act’s first birthday is the perfect time to remind families that there are many new opportunities to keep their kids healthy. For more information, contact the Department’s Help Center at 1-888-466-2219 or log on to www.healthhelp.ca.gov.

A trip to the emergency room (ER) can be a harrowing experience, just ask any of the more than 100 million Americans who visit one annually. What most people don’t realize is that sometimes convincing a health plan to cover the cost of a visit can be equally distressing.

Recently, the Department of Managed Health Care’s Help Center scored a significant victory on the behalf of consumers facing this predicament, recovering a total of more than $53,000 for health plan enrollees who were denied coverage of an ER visit.

When a health plan considers whether it is required to pay emergency room services, it must apply what is called the "prudent lay person" standard. This means that if a reasonable person in the same situation would believe that not getting immediate care could seriously jeopardize the individual's health, then the condition is considered to be an emergency and the health plan is required to pay for the emergency room services.

The Help Center found that a major health plan denied enrollees’ requests to pay ER claims without properly applying the prudent layperson standard. The Help Center found that, in handling the claims, the plan failed to review all of the pertinent facts before denying the claims. In addition, the Help Center investigation showed that the plan failed to use the prudent layperson standard when evaluating each case.

Consumer assistance is our main focus at the DMHC and our Help Center staff are specially trained to intervene on behalf of consumers with their health plans on any topic. If other consumers feel a claim for ER care has been denied incorrectly or if they have other questions related to their health coverage, the DMHC Help Center is available at 1-888-466-2219 or online at www.healthhelp.ca.gov.

One of the common consumer complaints received at the DMHC Help Center is not being able to see a doctor on a timely basis. A 2009 study found that in Los Angeles, new patients wait an average of 59 days to see a family practice physician. This is not just a California problem or unique to HMOs -- patients across the country are literally sick of having to wait weeks to see an in-network doctor. On January 17, 2011 new rules go into effect making California the first state in the nation to provide patients with predictable wait times.

These regulations are not a cure-all for what ails health care, but they take a big step forward in improving quality of care by shortening the time a California HMO patient has to wait to see the doctor. Part of the promise of health insurance is that patients will be able to find a doctor taking new patients or be within driving distance. The DMHC’s timely access regulations will make a significant difference for the approximately 21 million California HMO enrollees by ensuring that they have timely access to care that is appropriate for their conditions and consistent with good professional practice.

In crafting these regulations, the DMHC has worked countless hours with its health care partners to improve the entire system of care so that it is more responsive to enrollees' needs, whether they are an HMO, PPO or government-sponsored plan patient. We’ve all worked together to make good care even better.

While the law sets these time frames, health care providers can be flexible in scheduling appointments if a longer time frame is appropriate for the member’s health. It must be noted in the member’s record that a longer waiting time will not be harmful to the health of the member. If timely appointments are not available in geographic areas with provider shortages, a health plan must refer enrollees to available and accessible contracted providers in neighboring service areas. In the case of a preferred provider network, the plan must help enrollees locate accessible providers. The new rules place the burden of compliance on the health plan, not the doctor. A health plan must ensure that it has contracts with a sufficient number of doctors in each geographic area to serve its members. This means that plans must have a strong and varied provider network to enable appointments to be made within the specified timeframes.

The regulations specify that the usual waiting time for appointments will be:

• Within 48 hours of a request for an urgent care appointment for most 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 business days of a request for non-urgent primary care appointments
• Within 15 business days of a request for an appointment with a specialist
• Within ten business days of a request for an appointment with non-physician mental health care providers
• Within 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 full text of the regulation (28 Cal. Code Regs. § 1300.67.2.2) is available at http://wpso.dmhc.ca.gov/regulations/10CCRP/10CCRP.htm

Another important aspect of these new rules make it mandatory for health plan members to receive quicker answers on medical questions from health care providers. Now, health plans must have telephone triage or screening available so that you can speak to a qualified health professional to determine the urgency of your health condition. The triage service, operating 24 hours a day, seven days a week, cannot keep members waiting longer than 30 minutes. This will bring better service to health plan members and a quicker determination of the type of care needed.

Consumer assistance is our main focus at the DMHC, and our Help Center staff is specially trained to intervene on behalf of consumers with their health plans on any topic. I encourage consumers or providers who have questions or concerns about timely access to care or other health care issues to contact the DMHC’s Help Center at 1-888-466-2219 or online at www.healthhelp.ca.gov.

Recently the Department of Managed Health Care (DMHC) took historic action, collecting the largest fines for claims payment violations in the Department’s history. The nearly $5 million in fines against the seven largest health plans in the state for violations in paying claims to health care providers statewide sends the clear and consistent message that California’s hospitals and physicians must be paid fairly and on time. This action is part of the DMHC’s philosophical shift toward going after major acts of malfeasance that can affect thousands of enrollees or the doctors who treat them.

All seven plans were found to have violated the minimum legal threshold of paying 95 percent of their claims correctly. Audits found that not only did the plans not pay claims accurately, but often the second-chance appeal process of getting paid was also flawed. Five of seven plans were found to violate provider dispute resolution procedures, which is the method that providers must use to protest an underpayment or claims denial and get a corrected payment. This unfairly puts the burden on the provider to fight for payment, either within the plan, through the DMHC or through the courts.

Critics have dismissed the nearly $5 million in fines as “a drop in the bucket” suggesting that the amount is insignificant to health plans. However, the DMHC assessed these penalties in a manner designed to encourage restitution to providers, to punish plans according to the severity of the violation in relationship to their position in the marketplace, and to maintain balance in California's healthcare marketplace. It is also important to note that the fines are merely a starting point. Plans are required to make restitution to doctors and hospitals by identifying and reprocessing claims that have been underpaid. Restitution is expected to reach tens of millions of dollars, and that is a conservative estimate. Additionally, the public disclosure of the failure of plans to pay doctors and hospitals correctly is a great incentive for change.

Providers are struggling to stay afloat in a very difficult business environment. These fines underscore the DMHC’s commitment to helping providers be paid fairly. If changes are not made, the improper payment of provider claims increases the risk that our health care delivery system could grind to a halt. Along with fines and restitution, the DMHC has ordered changes to the health plans’ payment practices to ensure that tomorrows claims are paid accurately. These include dedicating additional staff and resources, providing additional management and oversight and revamping entire internal processes to avoid further violations of state law.

The DMHC also recently settled another issue, ordering Anthem Blue Cross to repay $1.6 million to seven hospitals that complained to the DMHC about denied financial claims. The DMHC also directed the plan to change the way that they paid “stop-loss” payments, which cover care above the contracted daily rate paid by a plan to a hospital. As a result of these changes, denied stop-loss payments have dropped by half each year for the past two years and it is estimated that Anthem-contracted hospitals statewide have now received more than $100 million in additional payments.

Providers who and have questions regarding restitution, would like to report a problem regarding claims payment or learn more about the Independent Dispute Resolution Process, please contact the Provider Complaint Unit at 1-877-525-1295, or go to www.healthhelp.ca.gov.

Perhaps one of the lesser-known, but most important, responsibilities of the DMHC is to monitor the financial solvency of health plans and risk-bearing organizations (medical groups and providers), so that California health plan enrollees can be assured that their medical care will be promptly paid and their doctor or hospital is able to continue to remain part of their health care network. To assist the DMHC in this effort, the Financial Solvency Standards Board (FSSB) was created.

The DMHC is standing up for doctors and hospitals, who are the only ones in the health care system taking a gamble on getting paid when they deliver care. As a consumer advocate also recently pointed out, financial solvency of providers continues to be a critical issue impacting the delivery of affordable health care to Californians. A recent trend of shifting HMO enrollment from commercial to state sponsored health plans is likely to accelerate under Health Care Reform and put even more economic pressure on plans and providers as they try to expand coverage and reduce costs.

The FSSB is composed of the DMHC Director, who selects members to serve as a volunteers for a three-year term, each an expert in some aspect of managed care, health care economics, or health care delivery. In the past, the FSSB was instrumental in assisting the DMHC in the development of financial solvency regulations for risk-bearing organizations (RBOs), including many medical groups contracted with health plans, an area in which the state previously had no oversight. These regulations require the use of financial criteria which has markedly reduced medical group financial failures which were prevalent in the early part of the current century.

The new slate of FSSB appointees held their first meeting on July 20; they are charged with advising the Director proactively on the implications of federal health care reform as it pertains to California’s health care landscape, trends, and regulations. They will also be assisting the DMHC in responding to a number of new federal regulations that affect the fiscal underpinnings of California’s health care delivery system.

In today’s unsteady economic climate, the DMHC must be continually aware of any impact to California’s health care market, including providers, and mitigate any negative effect on their financial viability. Especially because federal health care reform may have a profound effect on RBOs serving enrollees in government-sponsored programs, RBO solvency will be the FSSB’s priority focus. The Board will also examine the implications of emerging concepts such as advanced primary care (medical homes), bundled payments, accountable care organizations (ACOs), health care exchanges, rate management, risk relationships, and massive enrollee expansion, in order to help the DMHC respond to potential impacts on California’s health care marketplace, contracting processes, and solvency.

For more information about the FSSB, minutes of the meetings, and information about each of the Board members, as well as meeting agendas and a schedule of upcoming meetings, please go to: http://aboutTheDMHC/org/boards/fssb/org_fssb_default.aspx or contact dbalmer@dmhc.ca.gov

Last year, an estimated 240,000 California hospital patients contracted an infection while hospitalized, and 13, 500 of them died as a result of that infection. Almost all were preventable.

Called hospital-acquired infections (HAIs), they are the most frequently occurring complication of hospital care nationwide. Most of the organisms that cause the infections are present in the environment and do not make healthy people sick. Many people become “colonized” with these bacteria on their skin or in their noses without causing problems to them. But they can sicken or kill those who have compromised immune systems or who are weakened from disease or surgery.

Shocked by the prevalence of this preventable complication, the Department of Managed Health Care (DMHC) is taking steps to protect consumers by finding ways to eliminate preventable HAIs in California hospitals.

The DMHC partnered with the National Committee on Quality Assurance and created the Right Care Initative (RCI), a collaborative of health plans, medical groups, physician and hospital organizations, regulatory agencies, academic institutions, and quality experts) to address the HAI problem and tackle other health plan quality issues. Part of the answer found in researching the problem is to require medical professionals to use a simple five-step checklist to remind them to use sterile procedures when inserting a central line into a patient’s vein to provide fluids or medication.

The first checklist item? “Wash your hands with soap.”

Pressure on hospitals to eliminate preventable infections is increasing. Medicare no longer pays hospitals for added costs incurred by catheter or surgery-related infections. California and at least 27 other states now require hospitals to publicly report their HAI rates so that consumers can make an informed decision about which hospital they wish to use. Starting next year, HAI rates for all California hospitals will be posted on the Department of Public Health web site.

In the meantime, what can patients do to protect themselves?

Awareness is the key to avoiding the spread of infection. Patients can be vigilant and insist that all medical personnel – and visitors -- wash their hands or use alcohol-based hand cleaners each time they enter or leave their hospital room, to avoid carrying possible infections to or from other sites or other patients. Just wearing gloves is not enough – they only protect the wearer. Some particularly virulent bacteria can live on surfaces for up to three days. Anything the patient may touch, or that may touch the patient, must be kept sanitized -- the telephone, the TV remote, the computer mouse, the doctor's stethoscope, dressings, catheters.

Hand cleaner dispensers are usually located in lobbies and hallways, as well as in hospital rooms. To avoid carrying infections home, visitors should also use the hand cleaners each time they exit the hospital.

Consumers with questions about this issue, or others, may call the DMHC Help Center (1-888-466-2219 or online at www.healthhelp.ca.gov) where specially trained consumer assistance agents can provide information or intervene on their behalf when they encounter problems with their health plans. Click here for more information on the Right Care Initative.

In March, the Assembly Committee on Accountability and Administrative Review held a hearing to review the progress made on settlements between the DMHC, California Department of Insurance and the five major health plans fined in 2008 for the illegal rescission of health coverage.

We were proud to be able to tell our story. In early 2007, the DMHC became the first agency in the nation to take serious action to end the practice of illegal rescissions. Our ‘war on rescission’ resulted in unprecedented actions and strong new consumer protections that have forever changed the California health plan industry. In fact, we were invited to Washington D.C. to inform Congress of our accomplishments and our actions were held as a model for other state regulators.

As a result of DMHC actions, the number of rescissions industry-wide has dropped from 1,553 in 2005 to less than 10 in the last two years. The DMHC assessed and collected $13.6 million in penalties, the highest by any agency in the nation for illegal rescission; required health plans to offer guaranteed coverage to more than 3,400 enrollees; and returned more than $870,000 in expenses to consumers in a matter of months. Our actions to halt illegal rescissions have been comprehensive, swift and binding.

Moreover, all of DMHC actions were designed to carefully balance the need to ensure that not only those consumers who were unfairly rescinded were protected, but that all consumers in the individual market would have access to affordable health care coverage.

However, some of the media coverage of these hearings included unsubstantiated claims about the rights of enrollees under the settlements. This is unfortunate because one of the reasons the DMHC became involved in the rescission issue is that early court cases brought against health plans simply did not provide the long-term relief that consumers expected and deserved. In fact, five years later, the vast majority of the enrollees in those early cases have still not been reimbursed.

For example, Consumer Watchdog claimed that consumers could not use outside legal representation during the DMHC settlement process. This is untrue; enrollee notices about the availability of the settlements specifically stated that they could use an attorney if they wanted FOR ANY of the processes. Nothing in any of the settlements limited an enrollee’s access to an attorney. Enrollees always had the choice to be represented and/or seek advice and review of any settlement offer by an attorney.

Additionally, Consumer Watchdog claimed that the coverage offered to every rescinded consumer was usually a policy with a lower benefit than the wrongfully rescinded policy.

Again, this is not true. The coverage was offered with no questions asked about a consumer’s medical condition, which is virtually unheard of for individual health products. This waiver of underwriting was a direct result of DMHC requirements for the settlement and is seen by many as a major victory for consumers. The plan was required to offer coverage that was comparable, if not identical, as they had when they were rescinded. In addition, plans did not charge more for a policy or offer a lesser policy based on the consumer’s medical history, because they were not allowed to do so.

Although the DMHC was able to successfully outline its historic accomplishments to rid California of illegal rescissions, it was unfortunate that consumer advocates could not join the public agencies in celebrating this victory.

Unlicensed discount health cards can be hazardous to your wallet. Over the past few years, the California Department of Managed Health Care has been investigating discount health cards to determine if they offer any benefit for California consumers. The availability of these cards has been spreading rapidly in California and throughout the country, due in part to the high price and limited access to private health insurance coverage. But the faxes, spam e-mails, TV commercials and aggressive telemarketing claiming low monthly charges are usually selling little more than a card, not an actual discount on health care services.

Here's how it works: for an initial enrollment fee and a monthly charge, usually to a credit card or direct debit from a checking account, the consumer receives a card to take to his or her physician or hospital. But the doctor knows nothing about the card because he or she does not have a contract with the company.

The DMHC Help Center has received more than 1,000 calls and complaints from consumers about fraudulent discount health cards. The problem has become so bad, that the DMHC is now working on regulations to license discount health card companies that will specify significant protections to ensure that consumers are not victimized by unscrupulous operators.

Since September 2004, the DMHC has ordered 18 fraudulent discount health card companies to cease operations or become licensed. To date, the DMHC has licensed five discount health plans or products, but these new regulations will provide the framework for broad licensure of all discount health plans. In addition to licensing these plans, the DMHC will continue to aggressively shut down those who do not step forward and continue to deceive consumers.

Under the law, the DMHC, as the first stand-alone HMO oversight state agency in the nation, routinely reviews businesses that make commitments to provide certain health care services. It is this promise to arrange for access to a network of health care providers that gives the DMHC oversight of discount health companies, which are increasingly arranging to refer patients to providers via the membership card.

A "Consumer Alert" has been issued by the DMHC, giving tips on how to recognize potentially fraudulent cards. The Help Center is also available to help at www.healthhelp.ca.gov or 1-888-HMO-2219.

Lower health care costs for consumers is the goal of the DMHC and the Schwarzenegger Administration and we are committed to protecting consumers from the deceptive business practices used by some discount health companies. Our proposed regulations go a long way towards accomplishing this goal.