Report 2018-122 Recommendation 6 Responses

Report 2018-122: Department of Health Care Services: It Has Not Ensured That Medi-Cal Beneficiaries in Some Rural Counties Have Reasonable Access to Care (Release Date: August 2019)

Recommendation #6 To: Health Care Services, Department of

To obtain assurance that health plans throughout the State exhaust all of their reasonable options to meet the access requirements before requesting alternative access standards, DHCS should immediately require health plans to authorize out-of-network care if they do not demonstrate they have exhausted all of their reasonable options to meet the access requirements, unless the health plans can demonstrate that closer providers are demanding unreasonably high rates or have documented deficiencies in quality of care.

60-Day Agency Response

DHCS continues to disagree with this recommendation. DHCS does agree that MCPs must exhaust all of their reasonable options to contract with closer providers before an AAS is granted. However, DHCS already has existing processes in place to request supporting documentation for AAS and is further strengthening this process through a sampling and validation process.

  • Response Date: October 2019

California State Auditor's Assessment of 60-Day Status: Will Not Implement

Although DHCS references its processes for reviewing supporting documentation for requests for alternative access standards, it does not address how it would handle situations in which health plans are not able to demonstrate that they have exhausted all reasonable options for meeting the access requirements. Our recommendation specifies that DHCS should require those plans to authorize out-of-network care.

All Recommendations in 2018-122

Agency responses received are posted verbatim.