Timely Access to Medical Care

Publications
#5556.01

Timely Access to Medical Care

California law says that managed care plans must make sure that you receive access to healthcare in a timely manner.

California law says that managed care plans must make sure that you receive access to healthcare in a timely manner.1 The following are the timeframes for getting care:

Types of appointment & timeframes

  • A Non-urgent appointment with your primary care doctor within10 business days of your request.*
  • A Non-urgent appointment with a specialist within15 business days of your request.*
  • Non-urgent appointments for ancillary services (x-rays etc.) to diagnose or treat an injury, illness or other health condition within 15 business days of your request.*
  • A Non-urgent appointment with a non-physician mental health provider within 10 business days of your request.*
  • An Urgent appointment that does not need prior approval within 48 hours of your request.
  • An Urgent appointment that requires prior approval within 96 hours of your request.

Telephone Wait Times

Telephone access 24 hours a day, 7 days a week, to speak with a health professional to determine how urgent your medical needs are. Wait time cannot be more than 30 minutes.

Call customer service during normal business hours. Waiting time cannot be more than 10 minutes.

Exceptions

*Preventative care and periodic follow-up care.

*The appointment waiting time can be extended if your health care provider determines that a longer waiting time will not be harmful to your health.

Your primary care doctor can offer you an appointment with a primary care doctor, nurse practitioner, or physician’s assistant within the same or next day from the time you request an appointment. This is called “advanced access.” If you do not want this appointment, your appointment will be set for a later date.

What if there are not enough providers in your area?

The law says that if you cannot get a timely appointment in your area because there are not enough providers, then your health plan must help you get an appointment with the right kind of provider.

What you can do if you do not get timely access:

  1. Complain to your health plan provider.
  2. File a complaint by calling the Help-Line at the Department of Managed Care toll-free at (888) 466-2219, TDD: (877) 688-9891 or http://www.dmhc.ca.gov/fileacomplaint.aspx#.Vvlk6tIrKUk
  3. Contact Disability Rights California toll -ree at (800) 776-5746, TTY (800) 719-5798 or http://www.disabilityrightsca.org

 

 

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