In California, 1 in 14 children have a serious emotional disturbance that substantially limits their daily life functioning, and about 1 in 7 adults live with a mental illness everyday. Mental health conditions impact everyone, especially communities who are historically oppressed. For example, ethnic and racial minorities are more likely to experience the risk factors that can cause mental health disorders, while they often face additional barriers to accessing mental health treatment. Serious mental illness is much higher for low-income children and adults. Although mental health is among the most common health conditions in California, in 2019, more than half of adults who experienced mental illness did not receive treatment.
The COVID-19 pandemic not only exacerbated many Californians’ pre-existing mental health and substance use conditions, but also added new stressors and challenges, such as social isolation, grief, and trauma. In 2020, more adults reported that they have experienced serious psychological distress. The state also recorded a 40% increase in drug overdose deaths. Additionally, the suicide rates of youth ages 10-18 in California increased by 20%, while the psychiatric hospitalizations rates of youth ages 15-19 also increased by 9.1%. As we enter the fourth year of the pandemic, ensuring access to quality mental health care for our diverse California communities remains critical.
Existing Network Adequacy Requirements
Many health plans in California, including the majority of those that provide services to low-income people enrolled in Medi-Cal, California’s Medicaid program, are licensed by the California Department of Managed Health Care (“DMHC”). DMHC-licensed plans are subject to a set of California consumer protection laws called the Knox-Keene Health Care Service Plan Act of 1975 (“Knox-Keene Act”).
In October 2021, Senate Bill 221 was signed into law to amend the Knox-Keene Act to require licensed health plans to ensure that an enrollee receives a mental health or substance use disorder (non-urgent) follow up appointment with a provider within 10 business days of the prior appointment, effective July 1, 2022. SB 221 also required health plans to provide the enrollee an outside referral and arrange coverage outside the plan’s contracted network, if a health care plan or insurer is unable to meet the geographic and timely access standards with an in-network provider.
In September 2022, Senate Bill 225 was enacted to further require that licensed health plans incorporate timely access to care standards into their quality assurance systems. Effective January 1, 2023, SB 225 authorized DMHC to develop methodologies to demonstrate appointment wait time compliance and averages. It also authorized DMHC to review health plan network submissions annually for compliance with these requirements, as well as take compliance or disciplinary action against health care service plans or insurers who do not meet the standards the departments develop.
New Compliance Reporting Thresholds Starting 2023
Recognizing that the availability of in-network non-physician mental health professionals accepting new patients is an essential component of the health plan’s duty to provide or arrange covered health care services in a timely manner, beginning reporting year 2023, DMHC requires plans to report the number of non-physician mental health professionals accepting new patients within a network as a part of the annual network reporting process.
Starting reporting year 2023, DHCS will evaluate plans’ ability to comply with network adequacy standards using new compliance thresholds, which consists of a network compliance threshold (at least 75% of the non-physician mental health professionals in the network are accepting new patients OR at least 80% of non-physician mental health professionals locations in the network are accepting new patients) and a county compliance compliance threshold (at least 75% of counseling non-physician mental health professionals in the network are accepting new patients in each applicable county OR at least 80% of non-physician mental health professionals locations in each applicable county are accepting new patients). Plans are required to meet both the network compliance threshold and the county compliance threshold. A plan that does not meet the compliance threshold in reporting year 2023 in a network or an applicable county will be provided an opportunity to provide feedback or corrective action.
Like any network adequacy standards, the standards are only as robust as their monitoring and enforcement. NHeLP expects that the results of DMHC’s monitoring will be made publicly available, so that people can see how the plans in their region have performed, and to inform their future enrollment decisions. In addition, NHeLP encourages DMHC to make full use of the enforcement tools at its disposal to require corrective action of plans that fail to meet its established thresholds.
In addition, for 2023, DMHC will not require reporting in certain counties that are designated as rural, or designated by the Centers for Medicare and Medicaid Services as counties with extreme access conditions. Yet these are the places where access to behavioral health care tends to be the most difficult. DMHC has indicated its intent to explore approaches to reporting in these counties in the future, and NHeLP will be evaluating this closely.
Advocates in other states can learn from California’s experience. Measuring and monitoring network adequacy is a necessarily iterative process, and one that requires ongoing vigilance from regulators. As advocates and regulators learn more about where there are particular access problems, they must continue to refine the tools they use to measure access and ensure that all plans provide their enrollees with access to covered services.