The Watchdog over Health Care in California, the DMHC

Posted: July 21, 2016

by John Hansen

The DMHC Enforces Bills like SB 137, 1052, 282, 546, AB 339, and 374 to Protect California Consumers

The Department of Managed Health Care often plays the role of the enforcement arm of legislation related to health care in California.

According to SB 137, the DMHC regulates provider directories put out by California health insurance carriers like Anthem Blue Cross, Blue Shield of California and Health Net. After reviewing these directories, they found that 25% of the listings were incorrect.

In these directories, they found many doctors that were deceased or retired as well as hospitals and facilities that no longer provided health care in California. Thus the DMHC has put pressure on carriers to clean up their provider directories and only include physicians who are actually available in the network. Also, they will be mandating how the directories should be set up including search functions, etc. Mary Watanabe said, “This is a lot of work but it will make things better.”

According to SB 1052, the Department of Managed Health Care has been given the task of standardizing carrier formularies. Various insurance carriers offering health care in California have Rx prescription drug formularies that differ extremely in formatting. This is confusing to consumers and makes it difficult to understand and compare the various medicine coverages offered by the California health insurance plans. The DMHC will create a standardized format and require the carriers to all follow that format.

The DMHC also manages the Prescription Drug Cost Sharing Caps (AB 339), Step Therapy Exception Request (AB 374) and Electronic Prior Authorization System (SB 282) all related to insurance companies who offer health care in California. Also, according to SB 546, the Department of Managed Health Care will be assessing Large Group Rates for the first time.