California Issues Emergency Regulation on Access to Healthcare Providers

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During his second inauguration, California Insurance Commissioner Dave Jones, announced a new emergency regulation relating to access to healthcare providers.  According to an accompanying press release,

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.

Among other things, the emergency regulation requires health insurers in California 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.

There is some concern by industry groups that 1) depending on how the California Department of Insurance (“CDI”) chooses to enforce the regulation, health insurers could face significant fines based on their current arrangement and 2) this new regulation could impose significant costs on health insurers and these costs could be passed along to the insureds.

The emergency regulation became effective on January 30, 2015 and is scheduled to expire on July 30, 2015.    A copy of the regulation is here.