Health Care Reform: Recent News & Events

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DOI Issues Emergency Regulation on Provider Networks - Wednesday, January 7, 2015

Source: California Department of Insurance

January 7, 2015 – California’s Insurance Commissioner Dave Jones 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 addresses the problems identified with access to doctors, hospitals, and other medical providers in 2014, as many health insurers reduced their medical provider networks and/or shifted to offering Exclusive Provider Organization (EPO) health insurance 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.

“Californians and California businesses deserve better than what they have gotten from most health insurers and HMOs,” said Commissioner Jones. “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 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;
  • 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;
  • 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.

The emergency regulation will go into effect upon completion of review by the Office of Administrative Law (OAL). By law, emergency regulations go into effect more quickly than regular regulations.

To reade the full press release, click here.

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