What Can I Do if I Can’t Get Timely Access to Medical Care in California?

Having health insurance is not worth much if you cannot get medical care when you need it. Perhaps you have been told the first available specialist appointment is months away, spent weeks waiting for an authorization or referral, or found that none of the healthcare providers listed in your directory are accepting new patients – or are even still a part of your insurer’s network. Imagine if your doctor tells you that you need to see a specialist.

You begin calling providers listed in your directory, only to learn that the list is hopelessly out of date. You are sick, and your symptoms could be worsening, yet you are being left on your own to navigate an inadequate provider network. Under California law, there are specific standards for timely access to covered medical care.

If your delay in getting necessary medical treatment is a result of your health plan’s network or administrative delays, you may have options. State law establishes standards for timely access to urgent care, primary care, specialty care, mental health services, diagnostic testing, and physical therapy. If you have discovered that having health insurance does not mean you can actually use it when you need it, it could be time to speak with Attorney Scott Glovsky. Scott never hesitates to take on a large insurance corporation and will always fight for justice on behalf of his clients.

When Having Health Insurance May Not Guarantee Access to Care

If you have health insurance and your treatment is technically covered, it can be alarming to find that no doctor or specialist is available to treat you. In addition to finding that the in-network providers listed in your insurer’s directory are not accepting new patients, or that the earliest appointment could be months away, referral or authorization delays may prevent you from scheduling an appointment.

If you are a patient with cancer, a serious chronic illness, a progressive disease, a mental health issue, or a condition requiring specialty care, delayed access can be especially harmful to your health. California law establishes timely access to care for most health plans and insurers. A health insurer cannot avoid its obligations simply because the problem originates with the provider network rather than a formal denial.

The law requires covered health services to be provided appropriately for your condition and in a timely manner. Plans must also maintain adequate networks, appropriate policies and procedures, and quality-assurance monitoring systems. Your insurer must have processes in place that make it possible for you to obtain medical care in a timely manner.

Further, statutory deadlines do not authorize your insurer to make you wait that long. The requirement is clinically appropriate access, which means your condition may require an appointment sooner than the general maximum timeframe allowed. (Your healthcare provider can document your need for quicker access.)

How Long Can I Be Made to Wait for a Medical Appointment in California?

Generally speaking, under California’s “Timely Access to Care” law, managed health care plans must offer appointments within strict legal time limits, which are:

• Emergency services must be available 24 hours a day, 7 days a week.
• Urgent care that requires no prior approval must be available within 48 hours of the request.
• Urgent care that requires prior approval must be available within 4 days of the request.
• Routine primary care must be available within 10 business days of the request.
• Non-physician mental health or substance use care must be available within 10 business days of the request.
• For specialist physician care, you must be able to access that care within 15 business days of the request.
• Ancillary services, like x-rays, physical therapy, and labs must be scheduled within 15 days of the request.

Your insurer must answer customer service lines within 10 minutes during normal business hours, and an on-call or advice nurse must return your call within 30 minutes. Your doctor may schedule an appointment outside these windows of time if it is noted in your medical record that a longer wait will not harm your health. If your insurer cannot find you an in-network provider within these legal limits, they must help you find an out-of-network provider.

What if I Have a Medical Condition That Cannot Safely Wait That Long?

Perhaps you have a medical condition that cannot wait, even for the time allowed. It is important to understand that general appointment standards do not determine that waiting that long is medically appropriate for every patient. California law requires that your care be appropriate for your condition. If you have a more serious condition, ask your treating physician to clearly document your diagnosis, your symptoms, the progression of your disease, any risks created by a delay, and why earlier evaluation/treatment is medically necessary.

If your doctor suspects you have cancer, you have been diagnosed with a recurrence of cancer, you have rapidly worsening neurological symptoms, a progressive disease, a serious cardiovascular condition, severe psychiatric symptoms, or you need time-sensitive medications or treatments, you can ask for quicker medical access. If no in-network doctor is available to see you within the required time limits, contact your health plan and explain the situation, asking your insurer to locate an appropriate provider for your condition.

Under DMHC rules, if you are unable to obtain a timely appointment, your insurer must help you obtain an appointment with another appropriate provider, whether that provider is in-network or out-of-network. This is particularly important if your network has no appropriate specialist, the doctors listed as in-network are not accepting patients, medical providers are unable to offer timely appointments, or the geographic access to a medical provider is unreasonable.

What is a Network Gap Exception?

A California network gap exception refers to when an insurer’s health plan allows a patient to receive covered care from an out-of-network provider at in-network cost-sharing because the plan’s network is unable to provide the medically necessary covered service. For DMHC-regulated plans, California regulations require that a plan arrange covered services from out-of-network providers when necessary services are unavailable in-network. The cost to the patient cannot exceed the applicable in-network copays and deductibles.

So, if no in-network provider offers the covered service you need, the available in-network doctors do not have the expertise to treat your condition, there is no appropriate in-network provider who can see you within the timely access requirements, or the only appropriate providers are too far away, your insurer may have to provide a network gap exception. This is also true if the providers listed in the insurer’s directory are no longer accepting the insurance, are not accepting new patients, or cannot provide the required treatment.

If I Get a Network Gap Exception, Does the Out-of-Network Doctor Become In-Network?

If you obtain a network gap exception, your out-of-network medical provider does not necessarily become in-network. A network gap exception typically does not permanently turn an out-of-network physician into an in-network provider. Your insurer may authorize a provider to treat a particular service or course of treatment when it cannot provide a necessary in-network provider, but this is often a single-case agreement. California’s regulations distinguish between providers available through single-case agreements and providers that make up the plan’s regular network.

Regarding mental health and substance use disorder treatment, if a medically necessary treatment is unavailable in-network (including geographic and timely access standards), your plan must arrange out-of-network services and your cost must be no more than what you would pay if you were able to obtain the same services in-network. If your insurer claims another in-network doctor is available, network gap disputes can arise and may be complex.

While your insurer can deny your request for a network gap exception because the directory shows other in-network providers, simply identifying a doctor’s name does not necessarily mean that specific doctor can provide timely, appropriate care. Your insurer could give you five names: two might no longer accept your insurance, one might not be accepting new patients, and the other two might not be able to see you for months. So, the issue is not just about whether a specialist appears in the network directory. It is about whether that specialist can adequately provide the care you need in a timely manner.

Can My Insurer Make Me Travel Long Distances for Medical Care?

Network “adequacy” includes geographic accessibility, meaning that providers must be reasonably accessible. For policies that are regulated by California Department of Insurance (CDI), the geographic accessibility standards include:

• Primary care that is within 15 miles or 30 minutes of your home
• Specialists that are within 30 miles or 60 minutes of your home
• Mental health professionals that are within 15 miles or 30 minutes of your home
• An in-network hospital that is within 15 miles or 30 minutes of your home

There are certain geographic exceptions in areas with provider shortages. In some cases, approved alternative-access arrangements may require out-of-network access at in-network cost-sharing.

How Does California Law Affect Timely Access to California Medical Care?

Kaiser was required to pay a $50 million penalty and invest $150 million over the next five years to improve mental healthcare after a California state agency found that Kaiser failed to provide timely appointments, inadequately handled patient grievances, and exercised insufficient oversight of medical groups. Kaiser claimed the pandemic and the resulting mental healthcare surge were responsible for these issues.

California’s DMHC assessed $198.4 million dollars against health plans that violated timely access laws. California laws regarding health insurer violations have changed over the past few years. In fact, laws regarding health insurer violations have shifted heavily toward stricter accountability, faster claims processing, and steeper financial penalties when care denials are wrongful. California state regulators have aggressively advanced measures to prevent insurers from using “deny-and-delay” tactics that delay patients’ access to necessary medical treatments.

The Health Insurance Accountability Act (SB363) targets excessive commercial insurance denials after state data showed that the DMHC overturned 72 percent of health plan denials that reached its desk. This law seeks to levy fines of up to $1 million per case against insurers if more than half of their consumer appeals are overturned by state regulators in a single year.

The 30-Day Pay or Notify Rule (AB 3275) became effective on January 1, 2026. AB 3275 requires health care service plans, Medi-Cal managed care plans, and health insurers to reimburse or pay a claim within 30 calendar days of receipt. If the insurer contests or denies a medical claim, written notice must be issued within 30 days. Urgent Care Protections (AB 3260), which did not pass, would have broadened the state’s utilization reviews; any medical case in which an insured individual faces an immediate, serious threat to his or her health would have required evaluation and a decision within 72 hours for utilization reviews, or within 3 days for urgent grievances.

State regulators are also actively enforcing laws that provide penalties for insurers who fail to act after a patient wins a state appeal. The DMHC Help Center now issues serious fines against insurers that fail to implement Independent Medical Review decisions within the state-mandated 5 working days. This prevents insurers from administratively delaying care that the state has already decided is medically required.

In 2025, DMHC fined UnitedHealthcare Benefits Plan of California $475,000 for delaying payments for medical care and for failing to implement IMR decisions. What these California laws mean for you, if you belong to one of the managed care plans that protect 12.8 million Californians, is that you have specific rights to timely access to care.

Getting the Help You Need from The Law Offices of Scott Glovsky

If you need medical care, being told to wait – perhaps weeks, or even months – can put your health at risk. If your California health plan fails to provide timely access to a doctor, specialist, test, treatment, or other medically necessary care, you do have options. Attorney Scott Glovsky represents California policyholders who are in a dispute with their health insurer when it has failed to meet its obligations. Scott and his legal team will fight for you, your health, and your future. Contact the Law Offices of Scott Glovsky today to discuss your situation, understand your rights, and learn what steps you can take to get the medical care you need and deserve.