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Insurance commissioner issues emergency regulation requiring sufficient networks



January 09, 2015
Area(s) of Interest: Licensing & Regulatory Issues 

California Insurance Commissioner Dave Jones this week issued an emergency regulation that establishes stronger requirements for health insurers to create and maintain sufficient medical provider networks to provide timely access to medical care.


"Californians and California businesses deserve better than what they have gotten from most health insurers and HMOs,” Jones said. "This emergency regulation is necessary to make sure that health insurers establish and maintain adequate medical provider networks to meet the health care needs of their policyholders, to make sure medical provider directories are accurate, and to stop the practice of surprising consumers with huge charges for out-of-network providers who provide care without the patients' consent or foreknowledge."


The emergency regulations strengthen current rules and regulations and add new medical provider network requirements that require insurers to, among other things, include an adequate number of primary care physicians accepting new patients, an adequate number of primary care physicians with admitting privileges at network hospitals, build a network capable of the treatment of mental health and substance use disorders, adhere to appointment waiting time standards, and require network facilities to inform patients if an out-of-network provider will participate in non-emergency procedure or care, before the care is provided, so that the patient has an opportunity to decline the provider's participation.


Jones says if an insurance company does not comply with the new regulations, he can deny them the ability to sell insurance next year.


These regulations would only apply to plans regulated by the Department of Insurance, not plans regulated by the Department of Managed Health Care or in the Medi-Cal program.


The California Medical Association (CMA) has performed an initial review of the proposed regulations, and they appear to be a significant step forward for the state towards ensuring that provider directories are accurate and that networks are adequate. The regulations are consistent with a number of CMA recommendations made over the past year, such as requiring that insurers have clear, publicly available criteria over who is included in a network and that insurers demonstrate comprehensive quality assurance programs in many areas related to directories and networks.


Once the emergency regulations are noticed publicly by the Office of Administrative Law, the public will have five calendar days to submit comments. If approved, the regulations will be effective for 180 days, at which time they can be readopted on an emergency basis for another 90 days or go through the regular rulemaking process.

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