March 10, 2016
Area(s) of Interest: Payor Issues and Reimbursement
The California Medical Association (CMA) is pleased to support California Insurance Commissioner Dave Jones in his announcement today that regulations that establish stronger requirements for health insurers to create and maintain adequate medical provider networks have been approved by the Office of Administrative Law (OAL) and will go into effect today.
This move comes after emergency regulations were issued in January 2015 to help ensure patients can get timely access to care.
“Today’s announcement is a step toward ensuring patients have real access to timely care and that provider directories are accurate and up-to-date,” said Steven Larson, M.D., MPH, CMA president. “It’s important that patients be able to navigate the complex system and that it results in access to care. These permanent requirements will help California regulators monitor and enforce network adequacy so that patients will get the care they need in a timely manner.”
To address rising concerns about network adequacy, the commissioner’s new regulations strengthen and add new health care provider network requirements, including requiring health insurers to:
- Include sufficient numbers and types of physicians in the network to deliver covered services;
- Adequately provide for the treatment of mental health and substance use disorders;
- Include an adequate number of primary care physicians and specialists with admitting and practice privileges at network hospitals;
- Monitor and adhere to new appointment wait time standards;
- Regularly report information about the networks and changes to the networks to the Department of Insurance for review;
- Maintain accurate provider network directories available to the public and update them weekly; and
- Arrange out-of-network care at in-network prices when there are insufficient in-network care providers.
“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,” added Dr. Larson. “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.”