California Issues Regulation on Provider Networks

John GarnerCompliance, Legislative Updates, Resources

California’s Insurance Commissioner Dave Jones has issued an emergency regulation to establish stronger requirements for health insurers to create and maintain sufficient medical provider networks to provide timely access to medical care.

The emergency regulation issued by Commissioner Jones addresses problems with access to doctors, hospitals and other medical providers, as many insurers reduced their medical provider networks and/or shifted to offering exclusive provider organizations (EPOs– products with no out-of-network benefits). Consumers complained of having trouble getting appointments with doctors, traveling long distances to receive in-network medical care, or seeking care from doctors who appeared in their health insurer’s provider directory but who were not actually in the health insurer’s medical provider network.

The Commissioner’s emergency regulation strengthens and adds new medical provider network requirements, including requiring health insurers to:

  • Include an adequate number of primary care physicians accepting new patients to accommodate recent and ongoing anticipated enrollment growth (the summary released by the Department of Insurance did not define “adequate”);
  • Include an adequate number of primary care providers and specialists with admitting and practice privileges at network hospitals;
  • Consider the frequency and type of treatment needed to provide mental health and substance use disorder care when creating the provider network;
  • Adhere to and monitor new appointment wait time standards (the summary did not detail these standards);
  • Report information about the networks and changes to the networks to the Department of Insurance on an ongoing basis;
  • Provide accurate provider network directories to the Department and make them available both to policyholders and the public, so that those shopping for health insurance have this information as well;
  • Make arrangements to provide out-of-network care at in network prices when there are insufficient in-network care providers;
  • Require network facilities to inform patients that an out-of-network medical provider will participate in the non-emergency procedure or care, before the care is provided, so that the patient can decline the participation of the out-of-network provider if they so choose.  According to Commissioner Jones, he will have the power to order insurers to stop selling insurance in California if they do not comply with the regulation.
  • The Department of Managed Health Care regulates more than 90% of the health insurance sold in California and already has network adequacy requirements.
  • The emergency regulation will be noticed and then filed with the Office of Administrative Law (OAL) and go into effect upon OAL’s completion of its review.
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