Health Net's appointment accessibility and provider availability policies, procedures and guidelines for providers and health care facilities providing primary care, specialty care (including seldom used or unusual specialty services), 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), and 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.

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 within reasonable timeframes. 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 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, 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:

Health Net 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.

As required by applicable federal and state statutes and regulations, primary care physician (PCP) and specialty care practitioners (SCP) office hours must be reasonable, convenient and sufficient to ensure that they do not discriminate against members and members are able to access care within established time-elapsed access standards. PCP and SCP office hours must be posted in the provider's office. Health Net requires a PCP practice to be open at least 20 hours per week and a SCP practice to be open at least 16 hours per week for members to schedule appointments within 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 provide members with clear and simple instruction on after-hours access to medical care. Additionally, Medi-Cal participating providers must offer hours of operation to Medi-Cal members that are no less than the hours of operation offered to patients from other lines of business or to Medi-Cal fee-for-service (FFS) beneficiaries.

As required by applicable statutes, Health Net's participating providers must ensure that, when medically necessary, they have medical services available and accessible to members 24 hours a day, 7 days a week, and PCPs are required to have appropriate licensed professional 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 instructions about after-hours access to medical care (urgent/emergency medical care).

PCPs (or on-call physicians) should return phone calls and pages within 30 minutes and be available 24 hours a day, 7 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, Health Net provides triage and/or screening services 24 hours a day, 7 days a week through medical/nurse advice lines. Refer to the Triage and Screening Services/Advice Lines section below for further information.

Note: Although Health Net 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, 7 days a week.

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 other answering service can use as a guide for staff answering the phone. 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:

After-hours scripts are available in alternate formats and additional languages upon request request by calling the Customer Contact Center. Contact the Provider Network Management, Access & Availability Team for more information.

Providers are 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 phone 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 phone staff should have clear instructions about 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:

As defined in 28 CCR 1300.67.2.2(b)(5), Health Net provides 24-hour-a-day, 7 days a week triage or screening services by phone. This program is a service offered in conjunction with the PCP and does not replace the PCP's instruction, assessment and advice. According to community access-to-care standards, all PCPs must provide 24-hour phone service for urgent/emergent instructions, medical condition assessment and advice. The Health Net Member Services Department coordinates member access to the service, if necessary.

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

Health Net ensures that phone 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. Health Net provides triage or screening services for Medi-Cal members through medical advice lines as follows:

Health Net and its participating providers and practitioners do not discriminate against members who have physical or mental disabilities. Participating providers are required to provide reasonable access for members with disabilities 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.

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. Refer to Minors Consent section for more information.

Health Net provides PCPs with office policies and procedures to use as templates for the facility site reviews (FSRs). Refer to the Medi-Cal FSR PCP office management policy and procedure templates for more information. During Health Net's facility review process, a finding of any obvious physical barrier to accessibility for disabled members is noted. If any obvious physical barrier is found, Health Net discusses potential resolutions with the provider or PPG administrator. The provider indicates the resolutions on the facility site review (FSR) corrective action plan.

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. If a member has not selected a PCP, Health Net assigns one. 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:

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. When an appointment is missed, providers are required to attempt to contact the member a minimum of three times, via mail or phone.

According to the DMHC timely access regulations (28 CCR 1300.67.2.2) and to Health Net's Medical Records Documentation Standards policy and procedure (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.

The applicable waiting time for a particular appointment may be shortened or extended by the referring or treating licensed health care provider, or the health professional providing triage or screening services, as applicable, acting within the scope of his or her practice and consistent with professionally recognized standards of practice. If the licensed applicable health care provider has determined to extend the appointment wait time, the provider must document 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. The provider will notify the member of this decision, including an explanation of their right to file a grievance with Health Net. The record must be available to the Department of Health Care Services (DHCS) upon request.

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.

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 his or her practice. For detailed standing referral information, refer to Operations Manuals > Referrals > Standing Referral to a Specialist > Regular Standing Referrals.

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:

Providing members with a list of potentially available out-of-network providers does not meet the requirement to arrange for medically necessary services from an out-of-network provider. To ensure members have access to services within geographic and timely access standards, Health Net and its participating providers are responsible to:

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

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.

Phone 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 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.

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.

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

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 further information. For additional information refer to Authorization and Referral Timelines.

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 phone 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.

Compliance is measured by results from the Provider Appointment Availability Survey (PAAS) and the Provider After-Hours Availability Surveys (PAHAS) conducted via phone 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).

Health Net investigates and implements corrective action when timely access to care as required by Health Net's Appointment Accessibility for Medi-Cal policy and procedure (CA.NM.05) are 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 of or more metrics are noted as being non-compliant:

Health Net provides the following:

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 access that differs from the standards based on lack of practitioner and hospital availability. Regulatory approval is required for areas that vary from within the standard.

Health Net collects and analyzes all data to identify opportunities for improvement, which is communicated to the appropriate quality committee or department to review for recommendations. Health Net implements plan-wide corrective actions based on its assessment. These results and applicable actions for improvement are communicated to practitioners, providers and PPGs through Health Net's Quality Improvement Committee or through the activities of Provider Network Management.

Health Net's appointment accessibility and provider availability policies, procedures and guidelines for providers and health care facilities providing primary care, specialty care (including seldom used or unusual specialty services), 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) and 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 reasonable period of time appropriate for the nature of the member's condition and consistent with good professional practices. This includes, but is not limited to, 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:

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

As required by applicable federal and state statutes and regulations, primary care physician (PCP) and specialty care practitioners (SCP) office hours must be reasonable, convenient and sufficient to ensure that they do not discriminate against members and members are able to access care within established time-elapsed access standards. PCP and SCP office hours must be posted in the provider's office. Health Net requires a PCP practice to be open at least 20 hours per week and a SCP practice to be open at least 16 hours per week for members to schedule appointments within 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 provide members with clear and simple instruction on after-hours access to medical care. Additionally, Medi-Cal participating providers must offer hours of operation to Medi-Cal members that are no less than the hours of operation offered to patients from other lines of business or to Medi-Cal fee-for-service (FFS) beneficiaries.

As required by applicable statutes, Health Net's participating providers must ensure that, when medically necessary, they have medical services available and accessible to members 24 hours a day, seven days a week, and PCPs are required to have appropriate licensed professional 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 instructions about after-hours access to medical care (urgent/emergency medical care).

PCPs (or on-call physicians) should 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, Health Net provides triage and/or 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 Health Net 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.

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 other 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. Health Net's after-hours scripts provide easy to use messaging examples on how to direct members to emergency care services and who to talk to when they need urgent medical advice.

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

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

Providers are 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 about 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:

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 that 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 CalViva Health Medi-Cal Member Services Department coordinates member access to the service, if necessary.

The program allows California registered nurses (RNs) and other applicable licensed health care professionals to assess a member's medical condition and, through conversation with the caller, take further action, and provide self-care guidance, general health information, or recommend a visit to urgent care or the emergency room.

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. Health Net provides triage or screening services for Medi-Cal members through medical advice lines as follows:

Health Net and its participating providers and practitioners do not discriminate against members who have physical or mental disabilities. Participating providers are required to provide reasonable access for members with disabilities 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.

Health Net provides PCPs with office policies and procedures to use as templates for the facility site reviews (FSRs). Refer to the Medi-Cal FSR PCP office management policy and procedure templates for more information. During Health Net's facility review process, a finding of any obvious physical barrier to accessibility for disabled members is noted. If any obvious physical barrier is found, Health Net discusses potential resolution with the provider or PPG administrator. The provider indicates the resolutions on the facility site review (FSR) corrective action plan.

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. Refer to Minor's Consent section for more information.

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. If a member has not selected a PCP, Health Net assigns one. 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:

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. When an appointment is missed, providers are required to attempt to contact the member a minimum of three times, via mail or phone.

According to the DMHC timely access regulations (28 CCR 1300.67.2.2) and to Health Net's Medical Records Documentation Standards policy and procedure (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.

The applicable waiting time for a particular appointment may be shortened or extended by the referring or treating licensed health care provider, or the health professional providing triage or screening services, as applicable, acting within the scope of his or her practice and consistent with professionally recognized standards of practice. If the licensed applicable health care provider has determined to extend the appointment wait time, the provider must document 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. The provider will notify the member of this decision, including an explanation of their right to file a grievance with Health Net. The record must be available to the Department of Health Care Services (DHCS) upon request.

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.

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 his or her practice. For detailed standing referral information, refer to Operations Manuals > Referrals > Standing Referral to a Specialist > Regular Standing Referrals.

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:

Providing members with a list of potentially available out-of-network providers does not meet the requirement to arrange for medically necessary services from an out-of-network provider. To ensure members have access to services within geographic and timely access standards, Health Net and its participating providers are responsible to:

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 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.

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 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.

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.

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

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, [CCR T28 §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 further information. For more information refer to Authorization and Referral Timelines.

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).

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.

Compliance is measured by results from the Provider Appointment Availability Survey (PAAS) and the Provider 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).

Health Net investigates and implements corrective action when timely access to care as required by Health Net's Appointment Accessibility for Medi-Cal policy and procedure (CA.NM.05) are 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 of or more metrics are noted as being non-compliant:

Health Net provides the following:

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 access that differs from the standards, based on lack of practitioner and hospital availability. Regulatory approval is required for areas that vary from within the standard.

Health Net collects and analyzes all data to identify opportunities for improvement, which is communicated to the appropriate quality committee or department to review for recommendations. Health Net implements plan-wide corrective actions based on its assessment. These results and applicable actions for improvement are communicated to practitioners, providers and PPGs through Health Net's Quality Improvement Committee or through the activities of Provider Network Management.

Health Net's appointment accessibility and provider availability policies, procedures and guidelines for providers and health care facilities providing primary care, specialty care (including seldom used or unusual specialty services), 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) and 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 reasonable period of time appropriate for the nature of the member's condition and consistent with good professional practices. This includes, but is not limited to, 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:

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

As required by applicable federal and state statutes and regulations, primary care physician (PCP) and specialty care practitioners (SCP) office hours must be reasonable, convenient and sufficient to ensure that they do not discriminate against members and members are able to access care within established time-elapsed access standards. PCP and SCP office hours must be posted in the provider's office. Health Net requires a PCP practice to be open at least 20 hours per week and a SCP practice to be open at least 16 hours per week for members to schedule appointments within 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 provide members with clear and simple instruction on after-hours access to medical care. Additionally, Medi-Cal participating providers must offer hours of operation to Medi-Cal members that are no less than the hours of operation offered to patients from other lines of business or to Medi-Cal fee-for-service (FFS) beneficiaries.

As required by applicable statutes, Health Net's participating providers must ensure that, when medically necessary, they have medical services available and accessible to members 24 hours a day, 7 days a week, and PCPs are required to have appropriate licensed professional 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 instructions about after-hours access to medical care (urgent/emergency medical care).

PCPs (or on-call physicians) should return telephone calls and pages within 30 minutes and be available 24 hours a day, 7 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, Health Net provides triage and/or screening services 24 hours a day, 7 days a week through medical/nurse advice lines. Refer to the Triage and Screening Services/Advice Lines section below for further information.

Note: Although Health Net 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, 7 days a week.

n 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 other 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. Health Net's after-hours scripts provide easy to use messaging examples on how to direct members to emergency care services and who to talk to when they need urgent medical advice.

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

• English (PDF)
• Spanish (PDF)

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

Providers are 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 about 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, and 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 an authorization, which is binding and cannot be retracted.
• In the event of a hospitalization, the PPG or hospital must contact the Health Net 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.

As defined in 28 CCR 1300.67.2.2(b)(5), Health Net provides 24-hours-a-day, 7-days-a-week triage or screening services by telephone. This program is a service that 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 Community Health Plan of Imperial Valley Member Services Department coordinates member access to the service, if necessary.

The program allows California registered nurses (RNs) and other applicable licensed health care professionals to assess a member's medical condition and, through conversation with the caller, take further action, and provide self-care guidance, general health information, or recommend a visit to urgent care of the emergency room.

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. Health Net provides triage or screening services for Medi-Cal members through medical advice lines as follows:

• Triage and/or screening services/nurse advice help is available to members, 24 hours a day, 7 days a week through Health Net's State Health Programs (SHP) Member Service Department telephone line displayed on the back of the member's ID card. A representative connects the member to triage and/or screening services/nurse advice after verifying eligibility.

Health Net and its participating providers and practitioners do not discriminate against members who have physical or mental disabilities. Participating providers are required to provide reasonable access for members with disabilities 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.

Health Net provides PCPs with office policies and procedures to use as templates for the facility site reviews (FSRs). Refer to the Medi-Cal FSR PCP office management policy and procedure templates for more information. During Health Net's facility review process, a finding of any obvious physical barrier to accessibility for disabled members is noted. If any obvious physical barrier is found, Health Net discusses potential resolution with the provider or PPG administrator. The provider indicates the resolutions on the facility site review (FSR) corrective action plan.

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. Refer to Minor’s Consent section for more information.

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. If a member has not selected a PCP, Health Net assigns one. 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 (including emergency behavioral health care).
• Urgent care sought outside the service area, and under unusual or extraordinary circumstances provided in the service area when the participating medical provider is unavailable or inaccessible.
• 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 tests).
• Out-of-area renal dialysis services.
• 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.
• Behavioral health care is not covered by Health Net under its Medi-Cal managed care program. Accordingly, members may be eligible to self-refer to a behavioral health practitioner out-of-network through the mental health departments of members' counties of residence, depending on their Medi-Cal benefit coverage.
• Medi-Cal members may seek sensitive services, such as minor consent services, and family planning, sexually transmitted diseases and HIV testing and counseling services from qualified participating or out-of-network family planning providers, the local health department (LHD) and/or family planning clinics. Sensitive services for minors include sexual assault (including rape), drug or alcohol abuse, pregnancy, family planning, sexually transmitted infections, and behavioral health care.
• Medi-Cal members may access LHD clinics for immunizations.

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. When an appointment is missed, providers are required to attempt to contact the member a minimum of three times, via mail or phone.

According to the DMHC timely access regulations (28 CCR 1300.67.2.2) and to Health Net's Medical Records Documentation Standards policy and procedure (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.

The applicable waiting time for a particular appointment may be shortened or extended by the referring or treating licensed health care provider, or the health professional providing triage or screening services, as applicable, acting within the scope of his or her practice and consistent with professionally recognized standards of practice. If the licensed applicable health care provider has determined to extend the appointment wait time, the provider must document 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. The provider will notify the member of this decision, including an explanation of their right to file a grievance with Health Net. The record must be available to the Department of Health Care Services (DHCS) upon request.

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.

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 his or her practice. For detailed standing referral information, refer to Operations Manuals > Referrals > Standing Referral to a Specialist > Regular Standing Referrals.

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 for out-of-network providers must not exceed applicable copayments, coinsurance and deductibles.

Providing members with a list of potentially available out-of-network providers does not meet the requirement to arrange for medically necessary services from an out-of-network provider. To ensure members have access to services within geographic and timely access standards, Health Net and its participating providers are responsible to:

• Contact the out-of-network provider on behalf of the member to find out when appointments are available for medically necessary services.
• Schedule any initial and follow-up appointments for the member with an out-of-network provider.

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

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.

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 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.

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.

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

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, [CCR T28 §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 further information. For additional information refer to Authorization and referral Timelines.

• 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).

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 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.”

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).

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.

Medi-Cal Plans Medical Appointment Access Standards

ACCESS MEASURE	STANDARD	PERFORMANCE GOAL
Non-urgent appointments for primary care - regular and routine care (PCP)	Appointment within 10 business days of request	70%
Urgent care (PCP) services that do not require prior authorization	Appointment within 48 hours of request	70%
Non-urgent appointments with specialist (SCP)	Appointment within 15 business days of request	70%
Urgent care services (SCP & Other) that require prior authorization	Appointment within 96 hours of request	70%
First prenatal visit (both PCP and SCP)	Appointment within 2 weeks of request	70%
Well-child visit	Appointment within 2 weeks of request	70%
Preventive health, physical exams and wellness checks with PCP	Appointment within 30 calendar days of request	70%
After-hours care (PCP)	Ability to contact on-call physician after hours within 30 minutes for urgent issues Appropriate after hours emergency instructions	90%
Non-urgent ancillary services for MRI/mammogram/physical therapy	Appointment within 15 business days of request	70%
In-office wait time for scheduled appointments (PCP and SCP)	Not to exceed 30 minutes	70%
Provider office telephone callback during normal business hours	Provider callback within 1 business day	90%
Phone answer time at provider's office	Within 60 seconds	90%
Non-urgent appointment with a physician in a skilled nursing facility (SNF) or intermediate care facility (ICF)	Rural and Small Counties: Within 14 calendar days of request Medium Counties: Within 7 business days of request Large Counties: Within 5 business days of request	80%

Compliance is measured by results from the Provider Appointment Availability Survey (PAAS) and the Provider 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).

ACCESS MEASURE	STANDARD	PERFORMANCE GOAL
Urgent care1	Within 48 hours	90% or more of members with a clinical risk rating of urgent have access to urgent appointments within 48 hours
Non-life threatening emergency (NLTE)1	Within 6 hours	90% or more of members with a clinical risk rating of NLTE have access to an appointment within 6 hours
Access to care for life-threatening emergency1	Immediately	100% compliance with immediate referral to care
Rescheduled Appointments2	Appointment was scheduled to member's satisfaction	85% or more of members report their appointment was rescheduled to their satisfaction
Non-urgent appointments with behavioral health care physician (psychiatrist) for routine care3	Appointment within 15 business days of request	70%
Urgent care appointment with non-physician behavioral health care provider or behavioral health care physician (psychiatrist) that does not require prior authorization3	Appointment within 48 hours of request	70%
Urgent care appointment with non-physician behavioral health care provider or behavioral health care physician (psychiatrist) that requires prior authorization3	Appointment within 96 hours of request	70%
Non-urgent follow-up appointment with non-physician behavioral health care provider3	Within 10 business days of request	80%

1Assessed through care management software.

2Assessed through annual BH member experience survey (ECHO).

3Assessed through annual Provider Appointment Availability Survey (PAAS).

Health Net investigates and implements corrective action when timely access to care as required by Health Net's Appointment Accessibility for Medi-Cal policy and procedure (CA.NM.05) are 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 of or more metrics are noted as being non-compliant:

• 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 with one or more of the after-hours metrics.

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.

• Each PPG is required to send in a written improvement plan (IP) to include what interventions will be implemented 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 the standard meeting regulatory agency time frame compliance.
• The PPG is to return the IP within 30 calendar days.

• 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 the PNM and Contracting departments for further action.

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:

Geo-Access and Provider Availability Standards*

Availability Standards	Performance Threshold
Imperial	60 miles or 90 minutes
DHCS Core Specialists (Adult and Pediatric)	Cardiology/Interventional Cardiology*, Dermatology*, Endocrinology*, ENT/Otolaryngology*, Gastroenterology*, General Surgery, Hematology*, HIV/AIDS Specialists/Infectious Diseases*, Nephrology*, Neurology*, Obstetrics/Gynecology (Adult Only)*, Oncology*, Ophthalmology*, Orthopedic Surgery, Physical Medicine and Rehabilitation, Psychiatry*, Pulmonology*, Non-physicians/Mental Health Providers* *Telehealth optional
Practitioner/Provider Availability Standards	Performance Threshold
Member to full-time equivalent (FTE) PCP ratio	2,000:1
Member to FTE physician	1,200:1
Member to Behavioral Health Provider ratio: MD’s/DO (Psychiatrists) Psychologist Masters Level practitioner	6,250:1 2,875:1 1,450:1
Percent PCPs open practice	85% of PCPs accepting new members
Percent SCPs open practice	85% of SCPs accepting new members
Members age 0-21 to Qualified Autism Service (QAS) Provider ratio	5000: 1
Members age 0-21 to QAS Professionals and Paraprofessionals ratio	5000: 2

*Certain rural portions of the Plan service area may have access that differs from the standards, based on lack of practitioner and hospital availability. Regulatory approval is required for areas that vary from within the standard.

Health Net collects and analyzes all data to identify opportunities for improvement, which is communicated to the appropriate quality committee or department to review for recommendations. Health Net implements plan-wide corrective actions based on its assessment. These results and applicable actions for improvement are communicated to practitioners, providers and PPGs through Health Net's Quality Improvement Committee or through the activities of Provider Network Management.

Threshold Languages

Any non-English language that meets the following criteria for Medi-Cal eligibles within a county is designated as a threshold language. As Medi-Cal is an entitlement program, the criteria is based on those that may be eligible for services not those that are enrolled in the plan. Currently, Health Net has a total of 11 non-English languages that are required for translation.

• 3,000 within one county or five percent (5%), whichever is lower
• 1,000 within one zip code
• 1,500 within two contiguous zip codes

Per DHCS, “Threshold Standard Languages >3,000 per language or >5% of the Medi-Cal Population that speak the language per county. Concentration Standard Languages >1,000 per zip code or >1,500 per two contiguous.”

All members whose primary language has been identified as a threshold language by the Department of Health Care Services (DHCS) and Health Net receive written and oral information in that language. Health Net monitors member access to information and services in threshold languages through a variety of ways, including primary care site certification.

In Amador County, there are no non-English threshold languages.

In Calaveras County, there are no non-English threshold languages.

In Fresno County, the threshold languages are Spanish and Hmong.

In Imperial County, the threshold language is Spanish

In Inyo County, the threshold language is Spanish.

In Kings and Madera counties, the threshold language is Spanish.

In Los Angeles County, the threshold languages are Arabic, Armenian, Cambodian (Khmer), Chinese, Farsi, Korean, Russian, Spanish, Tagalog, and Vietnamese.

In Mono County, the threshold language is Spanish.

In Sacramento County, the threshold languages are Arabic, Chinese, Farsi, Hmong, Russian, Spanish, and Vietnamese.

In San Joaquin County, the threshold language is Spanish.

In Stanislaus County, the threshold language is Spanish.

Tulare

In Tulare County, the threshold language is Spanish.

Tuolumne

In Tuolumne County, there are no non-English threshold languages.