Access to Care and Availability Standards

Health Net's appointment accessibility and provider availability policies, procedures and guidelines for providers and health care facilities providing primary care, specialty care, behavioral health care, urgent care, ancillary services, and emergency care, are in accordance with applicable federal and state regulations, contractual requirements and accreditation standards. These access standards are regulated by the California Department of Managed Health Care (DMHC), the Centers for Medicare & Medicaid Services (CMS), the National Committee for Quality Assurance (NCQA) and the Department of Health Care Services (DHCS). The National Committee for Quality Assurance (NCQA) monitors medical standards for access to and availability of care and sets behavioral health time-elapsed appointment access standards.

Note: Behavioral health and chemical dependency services are administered by Health Net.

Health Net and its participating providers are required to demonstrate that, throughout the geographic regions of Health Net's service area, a comprehensive range of primary, specialty, institutional, and ancillary care services are readily available and accessible at reasonable times. Additionally, Health Net and its participating providers are required to demonstrate that members have access to non-discriminatory and appropriate covered health care services within a reasonable period of time, appropriate for the nature of the member's condition, and consistent with good professional practice. This includes, but is not limited to, practitioner/provider availability, waiting time and appointment access with established time-elapsed standards.

The following information delineates the medical appointment access standards, triage and/or screening access requirements, and telephonic access to health care services and the monitoring activities to ensure compliance:

Member Notification

Members are notified annually, via member newsletters or the Evidences of Coverage (EOC), of time-elapsed appointment access standards, the availability of triage or screening services and how to obtain these services.

Primary Care Physician and Specialist Office Hours

As required by applicable federal and state statutes and regulations, primary care physician (PCP) and specialist office hours must be reasonable and sufficient to ensure that members are able to access care within established time-elapsed access standards, and posted in the provider's office. To meet this requirement, Health Net requires a primary care's practice to be open at least 20 hours per week and a specialist's practice to be open at least 16 hours per week for members to schedule appointments within Health Net's established appointment access standards. During evenings, weekends and holidays, or whenever the office is closed, an answering service or answering machine should be utilized to ensure availability of services.

After-Hours Access Guidelines

As required by applicable statutes, PCPs must ensure that, when medically necessary, they have medical services available and accessible to members 24 hours a day, seven days a week. PCPs are required to have appropriate back-up for absences. Participating physician groups (PPGs) and PCPs who do not have services available 24 hours a day may use an answering service or answering machine to provide members with clear and simple instruction on after-hours access to medical care (urgent/emergency medical care).

PCPs (or on-call physicians) must return telephone calls and pages within 30 minutes and be available 24 hours a day, seven days a week. The PCP or on-call physician designee must provide urgent and emergency care. The member must be transferred to an urgent care center or hospital emergency room, as medically necessary.

Additionally, the plan provides triage and screening services 24 hours a day, seven days a week through medical/nurse advice lines. Refer to the Triage and Screening Services/Advice Lines section below for further information.

Note: Although the plan does not delegate triage and screening services, PCPs are still required to comply with these after-hours requirements since medically necessary services are required to be available and accessible 24 hours a day, seven days a week

After-Hours Script Template

In times of high stress, when members may have an urgent or emergent situation, it is important to provide clear messaging with call-back time frames and directions on how to access urgent and emergency care to prevent potential quality of care issues. Directing members to the appropriate level of care using simple and comprehensive instructions can improve the coordination and continuity of the member's care, health outcomes and satisfaction. Health Net has designed an after-hours script template that PPGs or physicians who have a centralized triage service or another answering service can use as a guide for staff answering the telephone. For PPGs or physicians who use an automated answering system/answering machine, this template can be used as a script to advise members how to access care. The script includes basic information that members need to access after-hours care, and modifications can be made according to PPGs' and physicians' needs.

Health Net makes the script available in the following threshold languages:

• Arabic (PDF)
• Armenian (PDF)
• Chinese/Cantonese (PDF)
• English (PDF)
• Farsi (PDF)
• Hmong (PDF)
• Khmer (Cambodian( (PDF))
• Korean (PDF)
• Russian (PDF)
• Spanish (PDF)
• Tagalog (PDF)
• Vietnamese (PDF)

After-hours scripts are available in additional languages upon request. Contact the Provider Network Management, Access & Availability Team for more information.

Answering Services

The provider is responsible for the answering service they use. If a member calls after hours or on a weekend for a possible medical emergency, the provider is held liable for authorization of, or referral to, emergency care given by the answering service. There must be a message immediately stating, "If this is an emergency, hang up and call 911 or go to the nearest emergency room."

Answering service staff handling member calls cannot provide telephone medical advice if they are not a licensed, certified or registered health care professional. Staff members may ask questions on behalf of a licensed professional in order to help ascertain a member's condition so that the member can be referred to licensed staff; however, they are not permitted, under any circumstance, to use the answers to questions in an attempt to assess, evaluate, advise, or make any decision regarding the condition of the member, or to determine when a member needs to be seen by a licensed medical professional. Unlicensed telephone staff should have clear instructions on the parameters relating to the use of answers in assisting a licensed provider.

Additionally, non-licensed, non-certified or non-registered health care staff cannot use a title or designation when speaking to a member that may cause a reasonable person to believe that the staff member is a licensed, certified or registered health care professional.

Health Net encourages answering services to follow these steps when receiving a call:

• Inform the member that if they are experiencing a medical emergency, they should hang up and call 911 or proceed to the nearest emergency medical facility.
• If language assistance is needed, offer the member interpreter services
• Question the member according to the PCP's or PPG's established instructions (who, what, when, and where) to assess the nature and extent of the problem.
• Contact the on-call physician with the facts as stated by the member.
• After office hours, physicians are required to return telephone calls and pages within 30 minutes. If an on-call physician cannot be reached, direct the member to a medical facility where emergency or urgent care treatment can be given. This is considered authorization, which is binding and cannot be retracted.

In the event of a hospitalization, the PPG or hospital must contact the Hospital Notification Unit within 24 hours or the next business day of the admission.

The answering service should document all calls. Answering services frequently have a high staff turnover, so providers should monitor the answering service to ensure emergency procedures are followed.

Triage and/or Screening Services/Nurse Advice Lines

As defined in 28 CCR 1300.67.2.2(b)(5), Health Net provides 24-hour-a-day, seven-day-a-week triage or screening services by telephone. This program is a service offered in conjunction with the PCP but does not replace the PCP's instruction, assessment and advice. According to community access-to-care standards, all PCPs must provide 24-hour telephone service for urgent/emergent instructions, medical condition assessment and advice. The Member Services Department coordinates member access to the service, if necessary.

The program allows registered nurses (RNs) and other applicable licensed health care professionals to assess a member's medical condition through conversation with the caller, take further action, and provide instruction on home and care techniques and general health information.

Health Net ensures that telephone triage or screening services are provided in a timely manner appropriate for the member's condition, and the triage or screening wait time does not exceed 30 minutes. Triage and/or screening services are available to members, 24 hours a day, seven days a week, through the Customer Service Department telephone number displayed in the back of the member's identification (ID) card. Members can select the triage or screening option to be connected.

Facility Access for the Disabled

Health Net and its participating providers and practitioners do not discriminate against members who have physical disabilities. Participating providers are required to provide reasonable access for disabled members in accordance with the Americans with Disabilities Act of 1990 (ADA). Access generally includes ramps, elevators, restroom equipment, designated parking spaces, and drinking fountain design.

Providers must reasonably accommodate members and ensure that programs and services are as accessible (including physical and geographic access) to members with disabilities as they are to members without disabilities. Providers must have written policies and procedures to ensure appropriate access, including ensuring physical, communication and programmatic barriers do not inhibit members with disabilities from obtaining all covered services.

Minor Consent Services

As defined in 42 CFR 2.14 (a) the term "minor" means a person who has not attained the age of majority specified in the applicable state law, or if no age of majority is specified in the applicable state law, age 18.

Under California state law, minor consent services are those covered services of a sensitive nature that minors do not need parental consent to access or obtain. The health care provider is not permitted to inform a parent or legal guardian without the minor's consent. Minors under age 18 may consent to medical care related to:

• Prevention or treatment of pregnancy (except sterilization) - California Family Code (CFC) §6925.
• Family planning services, including the right to receive birth control - CFC §6925.
• Abortion services (without parental consent or court permission) - American Academy of Pediatrics (AAP) v. Lungren, 16 Cal. 4th 307 (1997).
• Sexual assault, including rape diagnosis, treatment and collection of medical evidence; however, the treating provider must attempt to contact the minor's parent/legal guardian and note in the minor's treatment record the date and time of the attempted contact and whether or not it was successful. This provision does not apply if the treating provider reasonably believes that the minor's parent or guardian committed the sexual assault on the minor or if the minor is over age 12 and treated for rape - CFC §6927 and CFC §6928.
• HIV testing and counseling (for children ages 12 and older) - CFC §6926.
• Infectious, contagious, communicable, and sexually transmitted diseases diagnosis and treatment (for children ages 12 and older) - CFC §6926.
• Drug or alcohol abuse (for children ages 12 and older) treatment and counseling except for replacement narcotic abuse treatment - CFC §6926(b).
• Outpatient behavioral health treatment or counseling services (for children ages 12 and older) if in the opinion of the attending provider the minor is mature enough to participate intelligently in the outpatient or residential shelter services and the minor would present a danger of serious physical or mental harm to self or to others without the behavioral health treatment or counseling or residential shelter services, or is the alleged victim of incest or child abuse - CFC §6924.
• Skeletal X-ray - a health care provider may take skeletal X-rays of a child without the consent of the child's parent/legal guardian, but only for the purposes of diagnosing the case as one of possible child abuse or neglect and determining the extent of it - Cal. Penal Code §11171.
• General medical, psychiatric or dental care if all of the following conditions are satisfied: (1) The minor is age 15 or older, (2) The minor is living separate and apart from their parents or guardian, whether with or without the consent of a parent or guardian and regardless of the duration of the separate residence, (3) The minor is managing their own financial affairs, regardless of the source of the minor's income. If the minor is an emancipated minor they may consent to medical, dental and psychiatric care - CFC § 6922(a) and§ 7050(e).

Appointments and Referrals

Members are instructed to call their PCP directly to schedule appointments for routine care, except in the case of a life-threatening emergency. Health Net members must seek most care through their PCP. The PCP is responsible for coordinating all referrals for specialty care if the necessary services fall outside the scope of the PCP's practice. Exceptions to this process are:

• Emergency care
• Urgent care
• Obstetrics and gynecology (OB/GYN) for preventive care, pregnancy care or gynecological complaints
  • Female members have the option to directly access a participating women's health specialist (such as an OB/GYN or certified nurse midwife) for routine and preventive covered health care services for women (such as breast exams, mammograms and Pap smears).
• Member's self-referral to a behavioral health provider, which may be covered depending on the member's benefit coverage.
• Members with chronic life-threatening, degenerative or disabling conditions or diseases that require continuing specialized medical or behavioral health care, which qualify for a standing referral to a specialist under Health Net's national policy requirements. For example a member with HIV/AIDS, renal failure, or acute leukemia may seek a standing referral to a qualified, credentialed specialist
• Female members have the option of direct access to a participating women's health specialist (such as an OB/GYN or certified nurse midwife) within the network for women's routine and preventive covered health care services (such as breast exams, mammograms and Pap tests).

Missed Appointments

According to Health Net's Medical Records Documentation Standards policies and procedures (KK47-121230), missed appointment follow-up and outreach efforts to reschedule must be documented in the member's record or chart. When an appointment is missed, providers are required to attempt to contact the member a minimum of three times, via mail or phone. 

Appointment Rescheduling

According to the timely access regulations (28 CCR 1300.67.2.2) and to Health Net's Medical Records Documentation Standards policies and procedures (KK47-121230), when it is necessary for a provider or a member to reschedule an appointment, the appointment must be rescheduled promptly; in a manner that is appropriate for the member's health care needs. Efforts to reschedule the appointment must ensure continuity of care; and be consistent with good professional practice and with the objectives of Health Net's access and availability policies and procedures.

Shortening or Extending Appointment Waiting Time

The applicable waiting time for a particular appointment may be extended if the referring or treating licensed health care provider, or the health professional providing triage or screening services, as applicable, acting within the scope of their practice and consistent with professionally recognized standards of practice; has determined and documented in the member's record that a longer waiting time will not have a detrimental impact on the member's health as well as the date and time of the appointment offered.

Advanced Access

The PCP may demonstrate compliance with the established primary care time-elapsed access standards through the implementation of standards, policies, processes, and systems providing same or next business day appointments with a PCP, or other qualified health care provider, such as a nurse practitioner or physician assistant from the time an appointment is requested; and offers advance scheduling of appointments for a later date if the member prefers not to accept the appointment offered within the same or next business day.

Advance Scheduling

Preventive care services and periodic follow up care appointments, including but not limited to, standing referrals to specialists for chronic conditions, periodic office visits to monitor and treat health conditions and laboratory and radiological monitoring for recurrence of disease, may be scheduled in advance consistent with professionally recognized standards of practice as determined by the treating licensed health care provider acting within the scope of their practice. For detailed standing referral information, refer to Operations Manuals > Referrals > Standing Referral to a Specialist > Regular Standing Referrals.

Shortage of Providers

If it is determined that there is a shortage of one or more types of participating providers (including seldom-used or unusual specialty services) in a Health Net service area, Health Net and its participating providers are responsible for ensuring members are seen within the appropriate time-elapsed appointment standards [28 CCR 1300.67.2.2(c)(7)(B)]. To comply with applicable laws and regulations, and ensure timely access to covered health care services, a provider or PPG operating in a service area that has a shortage of one or more types of providers and cannot provide an appointment within the required time frame must:

• For primary care services - Refer members to available and accessible participating providers in neighboring service areas consistent with patterns of practice for obtaining health care services in a timely manner appropriate for the member's health care needs.
• For specialty services (including seldom-used or unusual specialty care) - Refer members to available and accessible participating providers in neighboring service areas. If a specialist is not available in neighboring areas within the network, the participating provider must refer the member to, and arrange for the provision of, an out-of-network specialist, when medically necessary for the member's condition for as long as the provider or PPG is unable to provide timely access within the network.
  • Member costs for medically necessary referrals to out-of-network providers must not exceed applicable copayments, coinsurance and deductibles.

  These requirements do not prohibit Health Net or its delegated PPGs from accommodating a member's preference to wait for a later appointment from a specific participating provider. If a member prefers to wait for a later appointment, document it in the relevant record.

Emergency and Urgent Care Services

Emergency and urgent care services are available and accessible to members within Health Net's service area 24 hours a day, seven days a week.

Providing Emergency and Urgent Care Services in the PCP's Office

The physician, registered nurse (RN), or physician assistant (PA) on duty is responsible for evaluating emergency and urgent care members in the office and making the decision to further evaluate and treat, summon an ambulance for transport to the nearest emergency room, directly admit to the hospital, or refer to a same-day visit at another provider or urgent care facility.

Provider Telephone Assessment

Telephone assessment of a member's condition, and subsequent follow-up, may only be performed by licensed staff (physicians, RNs, and nurse practitioners (NPs)) and only in accordance with established standards of practice.

Telehealth

Telehealth services are subject to the requirements and conditions of the enrollee benefit plan and the contract entered into between Health Net and its participating providers. Prior to the delivery of health care via telehealth, the participating provider at the originating site must verbally inform the member that telehealth services may be used and obtain verbal consent from the member. The verbal consent must be documented in the member's medical record. To the extent that telehealth services are provided as described herein and as defined in Section 2290.5(a) of the Business & Professions Code, Section 1374.13 of the Health and Safety Code, and Sections 14132.72 and 14132.725 of the Welfare and Institutions Code, these telehealth services comply with the established appointment access standards.

Interpreter Services

In order to comply with applicable federal and state laws and regulations, Health Net requires providers to coordinate interpreter services with scheduled appointments for health care services in a manner that ensures the provision of interpreter services at the time of the appointment. If an appointment is rescheduled, it is very important to reschedule the interpreter for the time of the new appointment to ensure the member is provided with these services. Refer to Interpreter Services for more information.

Cultural Considerations

Health Net and its participating providers must ensure that services are provided in a culturally competent manner to all members, including those who are limited-English proficient (LEP) or have limited reading skills, and those from diverse cultural and ethnic backgrounds. Refer to Language Assistance and Cultural Competency (Hospitals) for more information.

Prior Authorization Processes

Health Net requires prior authorizations to be processed and completed in a manner that assures appointments for covered health care services are provided in a timely manner, appropriate to the member's condition and comply with the requirements of the time-elapsed appointment access standards. If the appointment type requires prior authorization, obtaining authorization must be completed within the time frame for that visit or service to be offered. For example, expedited utilization management (UM) review processes and appointment scheduling for urgent care appointments for services that require prior authorization, [28 CCR 1300.67.2.2(c)(5)(B)], more commonly known as urgent pre-service requests, must be conducted concurrently, or the prior authorization turnaround timeline must be shortened to allow sufficient time to communicate the outcome to the member and/or the referring provider and ensure an appointment is offered to the member within 96 hours of the request. Refer to the Prior Authorization section for more information.

Routine Authorization (Pre-Service) – Deferral Needed

An initial decision may be deferred for 14 calendar days from the date of receipt of the original request if the referring provider, treating provider, or triaging health professional has determined and noted in the relevant record that a longer waiting time will not have detrimental impact on the health of the enrollee,” in accordance with Section 1367.03(a)(5)(H), and:

• Addditional clinical information is required.
• Consultation by an expert reviewer is required.
• Additional examination or tests are to be performed.
• The Plan can provide justification upon request by the State of the need for additional information and how it is in the member’s interest. (42 CFR 438.210(d) 438.404).

The decision may be deferred for an additional 14 calendar days (not to exceed a total of 28 calendar days from the date of receipt of the original request) only if: The member or the member’s provider requests an extension, or the Plan can provide justification upon request by the State of the need for additional information and how it is in the member’s interest.

Written Notification, Notice of Action – Deferral is sent to the enrollee and requesting provider within the initial five working days from receipt of the original request, or as soon as the Plan becomes aware that it will not meet the timeframe, whichever occurs first, and:

• Specify the additional information requested but did not receive; requesting only that information that is reasonably necessary to make a decision.
• Provide the anticipated date of decision.
• Advise the requesting provider that:
  “In accordance with Section 1367.03(a)(5)(H):
  • If this delay to obtain additional information and resulting delay will have a detrimental impact on the health of the member, you must contact the Plan.
  • If this delay will not have a detrimental impact on the health of the member, you must document this in the member record.”

• Advise the member that they have a right to file a grievance to dispute the delay.

Determination Timeline for a Decision following a Deferral

• When additional information is received: If requested information is received, a decision must be made within five working days from the receipt of information, not to exceed 28 calendar days from the date of receipt of the original request.
• Decision when additional information received is incomplete or not received:
  If the provider has not complied with the request for additional information, the Plan reviews the request with the information available and makes a determination within five working days of the expiration of the deferral notice, not to exceed 28 calendar days from receipt of the original request (Health & Safety Code 1367.01).

Expedited Authorization (Pre-Service) - Deferral Needed

An initial decision may be deferred for 14 calendar days from the date of receipt of the original request if the referring provider, treating provider, or triaging health professional has determined and noted in the relevant record that a longer waiting time will not have detrimental impact on the health of the enrollee,” in accordance with Section 1367.03(a)(5)(H), and:

• Additional clinical information is required.
• Requires consultation by an expert reviewer.
• Additional examination or tests are to be performed.

Written Notification, Notice of Action – Deferral: Written notification is sent to the member and requesting provider within the initial 72 hours from receipt of the original request, or as soon as the Plan becomes aware that it will not meet the timeframe, whichever occurs first, and:

• Specify the additional information requested; requesting only that information that is reasonably necessary to make a decision.
• Provide the anticipated date of decision.
• Advise the requesting provider that: 

“In accordance with Section 1367.03(a)(5)(H):

• ­If this delay to obtain additional information will have a detrimental impact on the health of the member, you must contact the Plan.
• If this delay will not have a detrimental impact on the health of the member, you must document this in the member record.”

Determination Timeline for a Decision following a Deferral

• When additional information is received: If requested information is received, a decision must be made within five working days from the receipt of information, not to exceed 28 calendar days from the date of receipt of the original request.
• Decision when additional information received is incomplete or not received:

If the provider has not complied with the request for additional information, the Plan reviews the request with the information available and makes a determination within five working days of the expiration of the deferral notice, not to exceed 28 calendar days from receipt of the original request (Health & Safety Code 1367.01).

Quality Assurance

Health Net has a documented system for monitoring and evaluating practitioner/provider availability and accessibility of care. At least annually, Health Net monitors appointment access to care and provider availability standards through member and provider surveys. At least quarterly, Health Net reviews and evaluates the information available to Health Net regarding accessibility, availability, and continuity of care, through information obtained from appeals and grievances, triage or screening services, and customer service telephone access to measure performance, confirm compliance, and ensure the provider network is sufficient to provide appropriate accessibility, availability and continuity of care to Health Net members.

At least on a quarterly basis, the Plan will review reports from the Quality Improvement Department regarding Incidents of non-compliance resulting in substantial harm to an enrollee that are related to access. The Plan will address areas related to network non-compliance with the regional Provider Network Management teams. Corrective actions will be implemented as applicable.

PPGs are responsible to monitor data provided by Health Net regarding their provider adherence to the following standards, as corrective actions may be required of providers that do not comply. Refer to the Corrective Action section below for further information.

Health Net's performance goals for access-related, time-elapsed provider criteria are available for providers' reference.

Health Net HMO and POS Plans Medical Appointment Access Standards

Compliance is measured by results from the Provider Appointment Availability Survey (PAAS) and Providers After-Hours Availability Survey (PAHAS) conducted via telephone by Health Net and the Consumer Assessment of Health Care Providers & Systems (CAHPS^®1) survey.

^{1 CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).}

¹Assessed through care management software.
²Assessed through annual BH member experience survey (ECHO).
³Assessed through annual Provider Appointment Availability Survey (PAAS).

Availability Standards

Health Net provides established availability standards and performance goals for providers. At least annually, Health Net measures, evaluates and reports geo-access and provider availability. Listed below are Health Net's performance goals for geo-access and provider availability-related criteria:

*Certain rural portions of the plan service area may have a standard that differs from within 15 miles/30minutes based on lack of practitioner and hospital availability. Regulatory approval is required for areas that vary from within 15 miles/30 minute standard.

Corrective Action

Health Net investigates and implements corrective action when timely access to care standards, as required by Health Net's Appointment Accessibility for commercial and SHP (Medi-Cal) appointment access policy and procedure (CA.NM.05), is not met.

Health Net uses the following criteria for identifying PPGs with patterns of noncompliance and will issue a corrective action plan (CAP) when one or more metrics are noted as being noncompliant:

• Appointment access - PPGs that do not meet Health Net's 90% rate of compliance/performance goal in one or more of the appointment access metrics.
• After-hours access - PPGs that do not meet Health Net's 90% rate of compliance/performance goal in one or more of the after-hours metrics.

PPG Notification of CAP

Health Net provides the following:

• PPGs receive a description of the identified deficiencies, the rationale for the corrective action and the contact information of the person authorized to respond to provider concerns regarding the corrective action.
• Feedback to the PPGs regarding the accessibility of primary care, specialty care and telephone services, as necessary.

CAP Minimum Requirements

• Each PPG is required to send in a written improvement plan (IP) to include what interventions will be implemented for each deficiency to improve access availability. The IP must include:
  • Date of implementation of the IP.
  • Department/person responsible for the implementation and follow-up of the IP.
  • Anticipated date that the IP is expected to produce outcomes that result in correcting the deficiency.
• The PPG is to return the IP within 30 calendar days.

CAP Follow-Up Process

• If the PPG fails to return a completed IP within the prescribed time frame, the Provider Network Management (PNM) Department is asked to intercede.
• PPGs demonstrating a pattern of noncompliance with access regulations and standards are subject to an in-office audit and may be referred to PNM and the Contracting departments for further action.