California’s Independent Medical Review: History, Impact, and Prospects for Change

For more than 10 years, California has mandated that consumers in most private health plans have the right to obtain an independent external review of any health plan coverage denials, known as Independent Medical Review (IMR).

The California IMR process is available to  more than 24 million Californians covered through health plans regulated by the California Department of Managed Health Care (DMHC) or health insurers regulated by the California Department of Insurance (CDI). The federal Affordable Care Act (ACA) mandates independent external review for all health coverage, including products for self-insured group plans. As coverage expands under health reform, this will greatly increase the number of health plan enrollees with access to IMR appeal rights.

Speakers at this CHCF briefing will discuss a new Kelch Associates analysis of the California IMR program’s history and impact, and prospects for change. The federal Department of Health and Human Services determined that California need not make any statutory changes to its IMR process to comply with the ACA. This means that changes to California’s IMR process, or the way California administers and evaluates it, will be state driven. The briefing will highlight several potential administrative improvements to position the state to more effectively deliver on the promise of a credible, transparent, and effective IMR program.

Participants are:

• Beth Capell, lobbyist/policy advocate, Health Access California
• Tony Cignarale, deputy commissioner, CDI
• Lyn Gage, health program manager, DMHC
• Andrew George, assistant deputy director, DMHC Help Center
• Patrick Johnston, president and CEO, California Association of Health Plans
• Deborah Kelch, president and CEO, Kelch Associates
• Carol Lee, president and CEO, California Medical Association Foundation
• Marian Mulkey, director, Health Reform and Public Programs Initiative, CHCF
• Sandra Shewry, director, State Health Policy, CHCF
• Jill Yegian, managing director, American Institutes for Research

For details: http://www.chcf.org/health-policy-office

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