Timely Access to Care in California: Lessons from Real-World DMHC Case Studies
Timely access to healthcare isn’t just a regulatory requirement in California; it’s a fundamental right for policyholders under managed care plans. Despite the protection in law, some insurers and health plans fail to meet their obligations, leaving patients without the care they need. The California Department of Managed Health Care (DMHC) enforces these rules, and recent enforcement cases provide a clear illustration of how timely access can be violated and what consumers can do about it.
In this post, we examine two real-world DMHC enforcement cases and explain why they matter for California policyholders. If you find yourself being denied timely access to care, or if your insurance claim was unreasonably denied, contact Gianelli & Morris to explore your options with a skilled and knowledgeable California insurance bad faith lawyer.
Case 1: Enforcement Matter 22-685
A Letter of Agreement dated March 26, 2025, from the California Department of Managed Health Care (DMHC) to Western Health Advantage (WHA) concludes an investigation into WHA’s violations of the state’s health plan regulations (the Knox-Keene Act) regarding Timely Access Reporting and Network Adequacy for the 2019 Measurement Year. The DMHC found that WHA failed to properly monitor and report information showing that its members could get appointments (especially for mental health services) within the required wait times. Specific violations on the part of this Northern California health plan were that it:
-
-
Failed to ensure complete reporting for behavioral health providers (like psychiatrists) that WHA delegated to another plan (Human Affairs International of California, or HAI) to manage.
-
Failed to monitor its network to ensure enough providers were available to meet regulatory appointment wait time standards.
-
Failed to review the data submitted by the delegated plan (HAI) on WHA’s behalf, which resulted in incomplete and missing information being sent to the DMHC.
-
WHA acknowledged its failure to comply. The DMHC is settling the matter with an administrative penalty of $35,000. Payment of this penalty settles all claims related to the specific instances of noncompliance described in the letter.
Case 2: Enforcement Matter Numbers: 18-799, 20-063, 21-428, 21-509, 21-680, 19-433, 22-062, 22-439, 23-190
In another enforcement matter, DMHC resolved an administrative hearing case and multiple enforcement matters stemming from L.A. Care’s alleged violations of the state’s health plan regulations (the Knox-Keene Act). L.A. Care Health Plan is the largest publicly operated health plan in the nation.
The DMHC alleged that L.A. Care failed to maintain its organizational and administrative capacity, resulting in multiple, significant failures that impacted both enrollees and healthcare providers. Failures impacting timely access to care laws and regulations include:
-
Massive Grievance Backlog: From 2017 to 2021, L.A. Care failed to timely resolve a total of 65,423 grievances and appeals.
-
Authorization Backlog: In 2021, L.A. Care experienced a backlog of 9,125 authorization requests for medical services due to issues like a new system launch, staffing shortages, and high COVID-19 volume.
-
Claims and Payment Issues: The plan failed to timely and accurately reimburse, deny, or pay claims, including failing to resolve tens of thousands of provider disputes in a timely manner between 2018 and 2023.
-
Oversight Failures: L.A. Care allegedly failed to adequately oversee its delegates (subcontracted health providers), resulting in issues like a failure to provide timely appointments with specialists, particularly related to the use of the eConsult system.
To resolve these enforcement matters, L.A. Care agreed to significant financial and operational requirements, including an Administrative Penalty of $13,500,000 that it must pay to the DMHC. On top of the administrative fine, L.A. Care must invest an additional $21,500,000.00 over three years into community initiatives in Los Angeles County, focusing on areas like behavioral health and other quality improvement strategies. As another part of the settlement agreement, L.A. Care is required to hire an independent Consultant for a minimum of two years to develop and oversee a Corrective Action Work Plan (CAWP). This plan must address all deficient areas, including:
-
-
Utilization management
-
Delegate oversight
-
Grievances and appeals
-
Claims payment and provider dispute resolution
-
Administrative capacity
-
The agreement is a settlement of claims and does not constitute an admission of fault or wrongdoing by L.A. Care.
What These Cases Teach About Enforcement
Both cases illustrate that California law is more than just words on paper. The DMHC actively enforces timely access requirements, and health plans can face consequences for failing to comply. For policyholders, these cases provide three key lessons:
-
Document everything: Keep detailed records of appointment requests, communications, and any delays.
-
Know your rights: Timely access rules under HSC § 1367.031(c)(1) and CCR § 1300.67.2.2(c)(1) give you the right to expect care without undue delay.
-
Regulatory complaints can work: Filing a complaint with the DMHC can lead to enforcement actions that correct systemic problems, improve access for all enrollees, and create leverage for individual claims. However, DMHC complaints are only one option for consumers and do not prevent you from pursuing legal action to recover monetary damages for the harm you suffered, which a DMHC resolution will not provide.
How an Experienced Attorney Can Help
Even with these protections, timely access cases can be highly complex. Plans may argue that delays were justified based on provider availability or the severity of the patient’s condition. Also, administrative processes and prior authorizations can obscure whether a delay constitutes a violation. Meanwhile, gathering evidence, preparing regulatory complaints, or pursuing legal claims requires expertise in both California health law and insurance law.
At Gianelli & Morris, we help policyholders face these challenges with a high degree of success. We review the facts, identify regulatory or contractual violations, and pursue enforcement or legal remedies to ensure you receive the care you need and compensation for harm you endured.
Statewide Reach and Support
Gianelli & Morris serves clients throughout California, including in major cities like Los Angeles, San Diego, San Francisco, Sacramento, San Jose, Oakland, Fresno, and Riverside. Whether your timely access issues involve primary care, specialty care, or mental health services, we have the experience and knowledge to help policyholders across the state assert their rights.
Take Action to Protect Your Rights
If you or a loved one has experienced delays or denials that prevented timely access to care, it’s important to act quickly. Keep detailed records of all interactions with your health plan. Then, file a complaint with the DMHC or consult an experienced health insurance attorney to evaluate your options for enforcement or legal claims.
Your health is your right, and timely access is the law. With the right guidance, you can ensure that your insurer meets its obligations and that you receive the care you deserve. For help throughout California, contact Gianelli & Morris in Los Angeles to review your case.
