Emergency regulation requiring health insurers to have sufficient medical providers goes into effect immediately

News: 2015 Press Release

SACRAMENTO, Calif. -Emergency regulations issued by California Insurance Commissioner Dave Jones establishing stronger requirements for health insurers to create and maintain medical provider networks to provide timely access to medical care were approved by the Office of Administrative Law and go into effect today. Commissioner Jones issued the emergency regulations at his inauguration last month, after pledging to continue in his second term his first term commitment to take action on behalf of consumers.

The Emergency Medical Provider Network Adequacy Regulation addresses the problems identified with access to primary care doctors, specialists and hospitals in 2014, as many health insurers reduced or narrowed their medical provider networks and/or shifted to offering Exclusive Provider Organization 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.

"When patients need medical care, it is critically important that there are sufficient primary care doctors, specialists, hospitals and surgical centers in the health insurer's network to provide timely access to medical care," said Commissioner Jones. "Getting more Californians signed up for health insurance is critically important, but it's not enough just to get people an insurance card, there have to be sufficient numbers of doctors, hospitals and clinics behind the insurance."

Patients have been surprised by huge bills from out-of-network doctors who were included in their treatment without notice or consent of the patient. Commissioner Jones' emergency regulation is one of the first in the nation to address these surprise bills.

"Some consumers have been forced to pay huge out-of-network charges when their health insurer fails to provide adequate medical providers in their network or when care is provided by out-of-network providers without even informing or asking the consent of the patient. 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 first informing the patient and getting their consent," Jones added.

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;
• Prevent "surprise" bills by requiring medical 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;
• 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.

Media Note:

Emergency regulation is available to the public.