The Department of Managed Health Care (DMHC) administers and evaluates healthcare laws and regulations. The following sections outline these laws, including The Knox-Keene Health Care Service Plan Act, regulations, and issues. Show
You will find additional topics relating to DMHC jurisdiction, administrative actions and opportunities for public participation in rulemaking proceedings.
Knox-Keene Health Care Service Plan Act of 1975These are the laws administered by the Department. The Knox-Keene Health Care Service Plan Act of 1975, as amended, is the set of laws or statutes passed by the State Legislature to regulate health care service plans, including health maintenance organizations (HMOs) within the State. The Knox-Keene Act is in the California Health & Safety Code, section 1340 et seq. In addition to statutes, the DMHC develops regulations with the help of our stakeholders: consumers, health plans, and providers, pursuant to the Administrative Procedures Act. These regulations are codified under title 28 of the California Code of Regulations. Regulations are used by the DMHC to implement, interpret, or make specific the laws enforced by the Department.
Newly Effective RegulationsRegulations become effective on a quarterly basis after filing with the Secretary of State. An emergency regulation becomes effective when filed with the Secretary of State. The text of the regulation is available within each regulation. Newly Effective Regulations Open Pending RegulationsThese are the draft regulations in which the Department is asking for public comments. Open Pending Regulations Closed Pending RegulationsThese are the draft regulation in which the comment period is closed. The Department is now reviewing the comments. Closed Pending Regulations Approved Pending RegulationsThe formal rulemaking process is completed and the office of Administrative Law has issued an approval. These regulations will become effective. Approved Pending Regulations Issues and RegulationsThis section lists the topics the Department is currently considering and evaluating and where you can submit comments on those topics. Issues and Regulations for the Upcoming Year Additional information about this website and the Office of Legal Services role in the rulemaking process is available by clicking the following link: Office of Legal Services Information The laws by which the Department regulates health plans come in two varieties: those statutes enacted by the Legislature and those regulations developed by the Department. The California Legislature has enacted a body of statutes collectively known as the Knox-Keene Health Care Service Plan Act of 1975, as amended. DMHC Monitoring Access to Services at Kaiser Permanente During StrikeThe California Department of Managed Health Care (DMHC) is continuing to monitor access to services for Californians enrolled in Kaiser Foundation Health Plan, Inc. (Kaiser Permanente) who may be impacted during a strike by behavioral health care workers in Northern California. "Ensuring California health plans provide timely access to care is a top priority for the DMHC. The law requires health plans provide enrollees with medically necessary care within timely access and clinical standards at all times, which includes during an employee strike," said DMHC Director Mary Watanabe. “I encourage any Kaiser enrollee experiencing issues with receiving appropriate access to care to contact Kaiser directly, or to contact the DMHC Help Center for further assistance." The DMHC Help Center is available at 1-888-466-2219 or www.HealthHelp.ca.gov. The DMHC Help Center provides help in all languages and all services are free. If you believe you are experiencing a medical emergency, dial 9-1-1 or go to the nearest hospital.  Health Plans Must Assist Enrollees Impacted by WildfiresHealth plans must ensure enrollees displaced by natural disasters, including wildfires, continue to have appropriate access to medically necessary health care services. This could include speeding up approvals for care, replacing lost prescriptions and ID cards, or quickly arranging health care at other facilities if a hospital or doctor’s office is not available due to the disaster. A consumer-focused fact sheet provides more information about what health plans are required to do to help enrollees impacted by a natural disaster. Joint Statement from CalHHS Agency Leaders on Continued Access to Reproductive Health ServicesCalifornia Health and Human Services (CalHHS) Secretary Dr. Mark Ghaly, Department of Health Care Services Director Michelle Baass and Department of Managed Health Care Director Mary Watanabe issued a joint statement following the U.S. Supreme Court’s decision in Dobbs v. Jackson Women’s Health Organization. "Today we link arms with all Californians as we commit to ensuring that reproductive health care is a right and not a privilege. "The Supreme Court’s decision counters our vision of a Healthy California for All, where health care is affordable, accessible, equitable and high-quality so it drives toward improved health outcomes; where equity is not just a word or concept, but the core value; and where we constantly pursue social and racial justice by not only lifting all boats but especially those boats that need to be lifted more…” Read the full statement. DMHC Releases 2021 Annual Report & InfographicThe DMHC released the 2021 Annual Report and Infographic, highlighting the Department’s achievements and activities during the year. The DMHC regulates the majority of health care coverage in California including 96% of commercial and public enrollment in state-regulated health plans. In 2021, 94 full service health plans licensed by the DMHC provided health care services to 28.4 million Californians. This included approximately 13.9 million commercial enrollees and approximately 14.5 million government enrollees. In addition to full-service health plans, the DMHC oversees 46 specialized health plans including chiropractic, dental, vision, behavioral health (psychological), and pharmacy. As of the end of 2021, the DMHC has assisted 2.6 million consumers through the Department’s Help Center. Select an image below to read the 2021 Annual Report or Infographic: DMHC Issues Guidance on Coverage of COVID-19 TherapeuticsThe DMHC issued an All Plan Letter (APL) regarding commercial health plan coverage of COVID-19 therapeutics, steps plans can take to encourage providers to use therapeutics, when appropriate, and directs plans to submit a description of how the plan is ensuring enrollees who need and are eligible for therapeutics have ready access to such treatment. Health plans must ensure enrollees for whom a COVID-19 therapeutic is medically necessary have access to these treatments within 48 hours if the plan does not require prior authorization or 96 hours if the plan requires prior authorization. Given treatment should be started as soon as possible after symptoms start, the DMHC strongly urges plans to waive any prior authorization requirements with respect to therapeutics and to ensure enrollees can receive needed treatment as quickly as possible. DMHC APL 22-017 – Coverage of COVID-19 Therapeutics DMHC Consumer Fact Sheets on COVID-19 Tests & VaccinesThe DMHC is taking action to protect consumers’ health care rights and ensure a stable health care delivery system during the COVID-19 pandemic. The Department is working closely with state and local leaders, health plans, providers and others in supporting actions to mitigate the spread and severity of COVID-19. This includes creating fact sheets to inform consumers about their rights to access free COVID-19 tests and vaccines: Consumer Fact Sheet on COVID-19 Testing Consumer Fact Sheet on COVID-19 Vaccines More information about the DMHC’s actions related to COVID-19 is available on the DMHC COVID-19 Response webpage. Which is responsible for reviewing health care provided by managed care organizations?CMS is responsible for reviewing and approving state requests to implement managed care under these authorities. All Medicaid managed care programs, regardless of authority, are subject to the provisions of Section 1932 and 42 CFR 438 unless specifically waived.
Which of the following is responsible for supervising and coordinating health care services for enrollees?Chapter 3 Insurance. What is the role of a managed care organization quizlet?Organization that delivers health care services without using an insurance company to manage risk and without a third party administrator to make payments. Most MCOs arrange medical services through contracts with physicians, clinics, and hospitals operating independently.
Who is responsible for the health of a group of enrollees that can be a health plan hospital physician group or health system?Chapter 3. |
Which of these is responsible for reviewing healthcare provided by managed care organizations
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