In 2021, the California Department of Managed Health Care (DMHC) Division of Plan Surveys began conducting investigations of full-service commercial health plans regulated by DMHC to assess barriers and challenges providers experience in providing behavioral health services. DMHC is investigating five health plans at a time and recently released the first five reports resulting from its initial round of investigations.

The DMHC Phase One Summary Report includes a list of the Knox-Keene Act violations that were identified for each of the investigated health plans and a summary of other barriers to care. Key violations identified include:

• Three health plans had at least one appointment availability and timely access violation.
• Three health plans had at least one utilization management violation.
• Four health plans had at least one quality assurance violation.
• Four health plans had at least one grievance and appeals violation.
• Two health plans had a cultural competency-related violation.

DMHC also identified a number of barriers to care, including:

• Three health plans were identified as not having a process for providing integrated behavioral health care services.
• Two health plans are conducting utilization management for behavioral health care services that are not subject to prior authorization, which could result in inappropriate denials or delays in care.
• Two health plans were unable to demonstrate they cover office-based opioid treatment and opioid treatment program therapy services.
• Five health plans did not have a comprehensive plan to identify potential disparities related to age, race, culture, sexual orientation, gender identity, income level and geographic location.
• One health plan’s provider complaints involved disagreement and misunderstanding about contract rates and payment amounts.
• One health plan and its behavioral health delegate lack customer service policies and procedures to ensure proficient, effective, and appropriate customer service for enrollees.

The health plans were given an opportunity to submit separate written responses to the barriers identified, describing any steps taken or to be taken to address the barriers. The individual Behavioral Health Investigation Report for each of the health plans, along with each health plan’s corrective action plan to address the Knox-Keene Act violations in the plan’s report, and any health plan statements, can be found on the DMHC website.

According to DMHC, the Knox-Keene Act violations noted in the reports, along with corrective action plans, will be referred for appropriate enforcement actions, which may include corrective actions and administrative penalties.

DMHC also provided recommendations to assist health plans in considering ways to address barriers and improve access to timely, appropriate behavioral health care for all enrollees.

2024 DMHC Behavioral Health Investigations

DMHC has been conducting an average of five investigations per year since 2021. The investigations seek to identify systemic changes that could be made to improve the delivery of behavioral health care. DMHC notes that these investigations will not include the Medi-Cal managed care population.

DMHC recently announced that the five health plans to be investigated in 2024 are:

• Chinese Community Health Plan
• Molina Healthcare of California
• UHC of California
• San Francisco Health Authority
• Aetna Health of California Inc.

The department is looking for providers willing to participate in interviews conducted by DMHC as a component of the investigations of the above-listed five health plans. The interviews will help DMHC to gain a comprehensive understanding of provider-specific barriers and challenges. Interviews conducted in 2023-2024 will likely be via phone or video conferencing.

DMHC is looking to interview both providers who have elected not to contract with the above five health plans, as well as contracted providers who have experienced barriers and challenges providing behavioral health services to their patients within the past two years. If you wish to participate in these interviews, contact DMHC at ProviderBHI@dmhc.ca.gov or (279) 666-5858. 

More information about the behavioral health investigations is available on the DMHC website.