***This blog post was authored by Zakkiyya West, Legal Intern, with supervision from Abbi Coursolle, Senior Attorney
Commercial California health plans are failing enrollees who need access to behavioral health services for mental health and substance use disorder care, recent investigations have shown. Across three rounds of investigations, the California Department of Managed Health Care found 70 Knox-Keene Act violations and 35 barriers to care across 14 health plans, spanning national, regional, and county-based plans.
What are the behavioral health investigations?
Since 2021, the California Department of Managed Health Care (DMHC) has conducted behavioral health investigations (BHIs) of the full-service commercial health plans it regulates.
The BHIs do not include any Medicare or Medi-Cal plans, or self-insured plans or any other plans not regulated by the DMHC. The BHI investigations were mandated by the legislature in 2020 to evaluate challenges enrollees face when accessing behavioral health services, and barriers practitioners experience in providing those services.
To date, three of five phases of the DMHC investigations have been completed, covering 14 of 23 health plans, and the findings reveal industry-wide problems, not isolated failures among health plans.
The DMHC licenses and regulates the vast majority of health plans in California. The BHIs are separate from the agency’s routine medical surveys or audits and are designed to answer one specific question: Are enrollees in DMHC-licensed plans able to access the behavioral health care services they are entitled to under California law?
Each investigation uses a standardized process that includes reviewing health plan documents and data, separately interviewing health plan staff, enrollees, and providers. The investigations cover eight main focus areas spanning three critical phases of patient care. The investigations begin by evaluating how easily patients can navigate and access care before an appointment. They then assess the quality of clinical delivery and treatments patients receive. Lastly, the DMHC reviews the post-care administrative process and patient experience feedback.
There are two categories of BHI findings: Knox-Keene Act violations and barriers to care. The Knox-Keene Health Care Service Plan Act (Knox-Keene Act) grants DMHC authority to regulate health care service plans to ensure those plans provide enrollees with access to quality health care services and protect and promote interests of enrollees. Knox Keene Act violations occur when health plans violate that California law. For the BHIs, any violations identified are referred to the Department’s Office of Enforcement to issue corrective action. The BHIs also identify “barriers to care,” which are current practices that the DMHC has determined do not rise to the level of a legal violation, but still make it harder for people to access care.
The BHI investigations found 70 Knox-Keene Act violations so far
With three of the five phases completed so far, the DMHC identified a total of 70 Knox Keene Act violations with 21 in Phase 1 across 5 plans, 10 in Phase 2 across 4 plans and 39 across 5 plans in Phase 3. Each phase investigates four to five health plans; however, the same violation categories have appeared consistently across the 14 plans reviewed so far.
The BHIs found three widespread Knox-Keene Act violations: quality assurance, found in 11 of 14 plans; appointment availability and timely access found in 10 of 14 plans; and grievances and appeals, found in 9 of 14 plans.
Quality assurance violations were found when plans failed to consistently review quality of care issues and ensure effective action was taken to improve care. Additionally, some of the BHIs found that customer service staff were not knowledgeable and competent in responding to enrollees’ questions or concerns. Appointment availability and timely access violations were identified when enrollees could not obtain timely mental health and substance use disorder treatments, whether provided by plan’s contracted doctors or out-of-network doctors. This violation type also captured situations where plans’ provider directories were inaccurate, and health plans failed to ensure enrollees who called about grievances or delays were offered appointments that meet timely access standards. Grievances and appeals violations were recorded when plans failed to identify, log, or properly respond to enrollee complaints, so complaints went untracked and unresolved.
The BHI investigations found barriers to care
Beyond Knox-Keene Act violations, the DMHC identified 35 separate barriers to care across all three phases. Cultural competency gaps were the single most widespread barrier across all three phases, found in 9 of 14 plans. Most plans lacked programs to identify and address disparities in care based on race, ethnicity, language, gender identity, sexual orientation, income level and geography. Research consistently shows these gaps may lead to diagnostic errors, harmful treatment interactions, negative response to medication, and enrollees not seeking or receiving care. This is likely to affect Black, Indigenous, and other People of Color (BIPOC) and LGBTQI+ populations who face higher rates of mental health conditions than their white and non-LGBTQI+ counterparts.
Additional Actions DMHC and Health Advocates Should Take
DMHC’s investigation reports spurred some movement among health plans through their corrective action plans (CAPs). Plans with violations in quality assurance, appointment availability, and grievances, responded with updated policies, increased staff training, new monitoring processes and vendor changes, however, the impact of these changes on access to care is yet to be seen.
These investigations have spurred plans to review their behavioral health policies and practices to identify and correct any Knox-Keene Act violations or other barriers to care, even if issues were not identified in their own BHI.
The DMHC should conduct annual follow-up reviews of plans that have gone through BHIs to determine whether they fully implemented their CAPs and whether those changes improved access to behavioral health care; this information should be publicly posted to ensure transparency.
DMHC has acknowledged that cultural competency and health equity gaps are a major barrier to behavioral health services. The DMHC can use the BHIs’ findings to enforce requirements on all regulated health plans to implement comprehensive cultural competency programs for behavioral health services, rather than plan by plan.
While statutory changes can take time, health advocates play a critical role in ensuring patients overcome these barriers and can access behavioral health services. Health advocates who assist commercial plan enrollees struggling to access mental health or substance use disorder care, can help advise enrollees to file a complaint with the DMHC’s Health Center (HealthHelp.ca.gov or 1-888-466-219). Plan enrollees can also get help from the Health Consumer Alliance, a statewide partnership that offers free phone and in-person assistance to help California residents resolve problems with their plans.