March 18, 2016
Area(s) of Interest: Payor Issues and Reimbursement Practice Management
The California Department of Insurance (CDI), which regulates most PPOs in the state, issued permanent regulations this week that require health insurers to develop and maintain adequate provider networks. This move comes after emergency regulations were issued in January 2015 to help ensure patients can get timely access to care.
While the California Department of Managed Health Care (DMHC), which regulates HMOs and certain PPO products, has had in place network adequacy standards for a number of years, CDI has not. These regulations will thus ensure that Californians, regardless of the model of care they choose to purchase, have access to timely health care.
“The California Medical Association (CMA) strongly agrees that it is necessary to put into place a permanent regulatory framework that equips the department to more effectively monitor insurance products moving forward,” said CMA President Steven E. Larson, M.D., MPH. “CMA surveys have identified major inaccuracies within directories over the last several years, but this move today will help make certain that patients are working with accurate lists that result in the ability to get medical care.”
The regulations, which go into effect immediately, provide significant protections for patients who have long faced challenges accessing care as the result of health insurers narrowing their provider networks. Significant provisions require health insurers to:
- Include adequate numbers and types of providers in networks;
- Provide for treatment of mental health and substance use disorders;
- Monitor and comply with established appointment wait time standards;
- Report changes to networks to CDI for review;
- Maintain accurate, publicly-available provider network directories and update them weekly; and
- Arrange for out-of-network care for patients at the in-network price when there are insufficient in-network providers.
CMA commented extensively on drafts of the regulations, pushing for comprehensive rules that would address the issue of access in a meaningful way while reducing confusion caused by inaccurate provider directories. Significantly, CMA successfully advocated for provisions requiring health insurers to:
- Obtain physicians’ written assent before including and listing them as a participant in a specified network; and
- Meet timely access and network adequacy standards at the lowest cost tier, if they are using tiered networks.