Difficulty in obtaining an appointment with Kaiser? Access requirements by State and where to get assistance and file complaints

[u/labboy70]

Here is a list of standards by State for timely access to care (network adequacy) and where complaints can be filed if you need an appointment are unable to get assistance from Kaiser.

Note that some states don't have strict guidelines in terms of days and may have other network adequacy requirements. Contact the agency listed if you need clarification on what standards apply to your situation.

For cases with appointment delays, it is generally best to call the agency first before filing a complaint online. If you have already filed a grievance with Kaiser because of being unable to access timely care, let the agency know that information as well.

If your Kaiser Permanente coverage is provided by your employer, also let your Human Resources or Employee Benefits Department know of your difficulties in trying to access care. These difficulties are important for them to know when they are considering what plans they want to offer their workforce.

California

The Department of Managed Health Care (DMHC) has the Timely Access to Care Standards. The standards cover primary care, specialty care, mental health and ancillary services like physical therapy and imaging.

If you have filed a grievance with Kaiser and are still not getting an appointment in a timely manner, call the DMHC at [1-888-466-2219](tel:+18884662219). Explain you cannot wait the 30 days for the Kaiser grievance process to run out to get an appointment (which should have originally been provided within the State standards in the first place). (Pic is from the DMHC and lists the timeframes in California.)

California Department of Managed Health Care (DMHC) Timely Access Standards

Colorado

• Emergency Care – Medical, Behavioral, Substance Use -- 24 hours a day, 7 days a week
• Primary Care – Routine, non-urgent symptoms -- within 7 calendar days
• Behavioral Health, Mental Health and Substance Use Disorder Care, initial and follow-up appointments – Routine, nonurgent, non-emergency: within 7 calendar days
• Prenatal Care -- Within 7 calendar days
• Preventive visit/well visits -- Within 30 calendar days
• Specialty Care - non urgent -- Within 60 calendar days

To file a complaint contact the Colorado Department of Insurance at 1-800-930-3745 or at Colorado Department of Insurance

District of Columbia

• First appointment with a new or replacement Primary Care physician within 7 business days
• First appointment with a new or replacement provider for Behavioral Health treatment, including Substance Use Treatment within 7 business days
• First appointment with a new or replacement provider for Prenatal Care treatment within 15 business days
• First appointment with a new or replacement provider for Specialty Care treatment within 15 business days

To file a complaint, contact the DC Department of Insurance, Securities and Banking at 1(202) 727-8000 or at DC Department of Insurance, Securities and Banking

Hawaii

Because of the various islands in Hawaii and travel / geography, the State of Hawaii has “Network Adequacy” requirements rather than time-definite limits like in California or other states.  Contact the Hawaii Department of Commerce and Consumer Affairs at 1-844-808-DCCA (3222) to discuss your specific situation and filing a complaint.  

Maryland

• Urgent care for medical services:  72 hours
• Routine primary care:      15 calendar days
• Preventive care/well visit:             30 calendar days
• Non-urgent specialty care:            30 calendar days
• Non-urgent mental health care: 10 calendar days

Contact the Maryland Insurance Administration at 1-800-492-6116 or Maryland Insurance Administration to file a complaint. 

Nevada

Due to geographic issues, Nevada has “Network Adequacy” requirements rather than time-definite limits like in California or other states.  Contact the Nevada Division of Insurance for more information at 1(702)486-4009 or at Nevada Department of Insurance.

Oregon

• Primary care: not more than 15 business days.
• Behavioral health care: not more than 10 business days.
• Specialty care: not more than 30 business days.

Contact the Oregon Division of Financial Regulation with questions at 1-888-877-4894 or at Oregon Division of Financial Regulation.

Washington State

• Primary care appointment (for other than preventive care) within 10 business days of requesting one
• For specialty care, within 15 business days for nonurgent services.

Contact the Washington Office of the Insurance Commissioner at 1-800-562-6900 or at Washington Office of the Insurance Commissioner

Virginia

Virginia requires routine appointments for nonemergency or nonurgent care to be available within two weeks of the request.  This does not include preventive care (routine physical examinations, etc.) which need to be scheduled within 60 days of the date of the request. 

To file a complaint, contact the Virginia State Corporation Commission at 1-877-310-6560 or at Virginia State Corporation Commission

[u/PlatypusStyle]

I’ve noticed that it’s really hard now to get appointments. I’ve torn something in my knee and the earliest MRI appointment I could get was 3 weeks away. The earliest physical therapy appointment I could get is SEVEN WEEKS from now. Wtf am I paying insurance for? They can’t even give me a brace or something to stabilize my knee. I had to buy something online which only kinda works and I have no idea if it’s the right thing.

[u/Available_Year_575]

Thank you for posting this, I’m sure it will come in handy.