Provider Network Adequacy
When you buy health insurance, you need to be able to use it when you need health care. That means there must be enough doctors and hospitals in you area who accept your insurance. The doctors and hospitals also need to be close enough so you can actually visit them. This idea is known as "provider network adequacy".
Insurers are required to have adequate provider networks. This means they must provide reasonable access to a sufficient number of providers and hospitals. These providers and hospitals are also known as your network.
You should know which providers and hospitals are in your network. It is important because you may pay more if you get heath care outside of your network. In some cases, you may have to pay the entire bill, so read your insurance policy carefully. You can call your insurer if you have any questions. You can also contact our Consumer Hotline for help.
Regulating Network Adequacy
To protect consumers, we review each plan's provider network to make sure that there is adequate access to providers and facilities in a carrier's service area. We do this to help you avoid long wait times to see a doctor and not have to travel unreasonable distances. Here is what we look at in greater detail:
- General availability of providers in a geographic area. Availability will vary depending on population, urban density, and the provider's willingness to enter in reasonable contracts.
- Medical care referral patterns and hospital admission privileges. We analyze whether the providers requiring the use of facilities are able to admit their patients to network facilities. For example, obstetricians must have admitting privileges to network hospitals for delivery services. Hospital-based providers (for example, radiologists, pathologists, and emergency room physicians) may not be part of the same network as the facility, or may not be in any network.
- Geographical barriers may exist that limit access to care.
- Location and availability of essential community providers (including mental health and substance abuse providers).
- Availability and access to transplant centers and other medically intensive services as well as the availability of critical care services such as advance trauma centers, burn units, etc....
- Availability of provider types as well as whether providers are accepting new patients.
An adequate provider network must include providers and/or facilities with the sufficient capacity to accept covered persons:
- At least one full-time physician per 1,200 covered persons; at least one full-time primary care physician per 2,000 covered persons.
- Primary care network providers within 30 minutes or 15 miles of each covered person's residence or workplace.
- Medically required network specialists with sufficient capacity to accept covered persons within 60 minutes or 30 miles of a covered person's residence or workplace.
- Mental health professionals within 30 minutes or 15 miles of a covered person's residence or workplace.
- A network hospital within 30 minutes or 15 miles of a covered person's residence or workplace.
Other Regulators' rules
These network adequacy rules only apply to insurers regulated by us. Plans regulated by the California Department of Managed Health Care (DMHC) operate under a different set of laws to determine network adequacy. Visit DMHC's Health Care Rights page for more information on network adequacy standards for HMOs and some PPOs.
Network Adequacy Review
There have been many changes in health coverage in light of the Affordable Care Act (ACA) and recent state legislation. In our ongoing efforts to protect you, the Insurance Commissioner is exploring changes to our network adequacy requirements through amended regulations. We will post more information about the process when it becomes available.