New Rules Designed to Limit Narrow Provider Networks Go Into Effect


New regulations requiring California health care insurers to follow stricter guidelines for provider network adequacy, out-of-network notifications and accuracy of provider lists when dealing with the state Department of Insurance went into effect on Monday, February 2.

California Insurance Commissioner Dave Jones (D), who was re-elected in November, used the occasion of his Jan. 5 inauguration to file for the stronger set of regulations. The state Office of Administrative Law approved the new rules Friday.

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 and 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 the patient has an opportunity to decline the provider's participation.

The new regulations require insurers to:

  • Adhere to new standards for appointment wait times;
  • Offer an adequate number of physicians, clinics and hospitals to patients who live in certain areas;
  • Provide an accurate list of in-network providers;
  • Provide out-of-network care options for the same price as in-network care when the number of in-network providers is insufficient; and
  • Report to DOI information about their networks and any changes.

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

These regulations will only apply to the preferred provider organization (PPO) plans regulated by the Department of Insurance, not plans regulated by the Department of Managed Health Care or those in the Medi-Cal program. MORE


CaliforniaHealthline,org 2/3/2015