California’s Insurance Commissioner Dave Jones issued an emergency regulation to establish stronger requirements for health insurers to maintain sufficient medical provider networks to provide timely access to medical care.
CommissionerJones issued the order on Jan. 5, immediately following his inauguration for a second term. He said it was needed to address problems consumers were having getting access to doctors, hospitals, and other medical providers.
During 2014, he noted, many health insurers reduced their medical provider networks and/or shifted to offering Exclusive Provider Organization (EPO) products with no out-of- network benefits.
Consumers reported having trouble getting appointments with doctors, traveling long distances to receive in- network medical care, or seeking care from doctors who were listed in their health insurer’s provider directory but who were not actually in the insurer’s provider work.
The emergency regulation require health insurers to:
- Include enough primary care physicians who are accepting new patients to accommodate enrollment growth;
- Include enough primary care providers and specialists with privileges at network hospitals;
- Consider the demand for mental health and substance abuse when creating their provider network;
- Monitor appointment wait times;
- Report changes to their networks to the Department of Insurance;
- Provide accurate provider directories to the Department, policyholders and the public;
- Provide out– at in- prices when there are insufficient in-network providers;
- Require network facilities to inform patients in advance if an out-of- network provider will participate in a non-emergency procedure, so the patient can decline the services of the out-of- provider if they choose.
The emergency regulation will be noticed and then filed with the Administrative Law (OAL) and go into effect upon OAL’s completion of its review.
