CA State Updates - 2015 Jan 25 No.02

On July 27, 2015, California’s Office of Administrative Law voted to approve an emergency regulation submitted by the California Department of Insurance. The regulation amends Title 10 of the California Code of Regulations that requires health insurers to maintain adequate medical provider networks that meet the needs of their policyholders, maintain accurate provider directories and requires disclosure of out-of-network providers who may participate in a patient’s planned care.

The amended provisions include:

Insurers must ensure their networks have an adequate number of primary care physicians accepting new patients.The network must include providers of the following services: Behavioral health therapy, substance use disorder, psychiatric inpatient hospitalization, detoxification, psychological testing and outpatient retail pharmacies.Participants must be able to access information about mental health and substance use disorder services, such as benefits and providers, by calling a customer service representative during normal business hours.The network must include an adequate number of providers with admitting and practice privileges at network hospitals.If medically appropriate care cannot be obtained from a network provider, then the insurer shall arrange for care from a non-network provider with the patient only responsible for in-network cost sharing.The network should have adequate capacity and availability of licensed health care providers to allow for appropriate appointment waiting times. For example, a participant should not have to wait more than 48 hours for an urgent care appointment that does not require prior authorization; 10 business days for a non-urgent primary care physician or mental health provider appointment; 15 days for a non-urgent specialist appointment.The network must ensure triage or screening services are available by telephone, and that the waiting time for these services does not exceed 30 minutes.Insurers shall also ensure that during normal business hours, the waiting time for a person to speak with a customer service representative does not exceed 10 minutes.Policies that cover pediatric dental and/or vision essential health benefits must assure that there are adequate oral and vision providers, including general and specialists, to accommodate anticipated enrollment growth.Online network provider directories must include specific information about each provider and be made available to both covered persons and consumers. The network provider directory must be updated weekly.

While the new regulations apply to insurers, employers should understand the new safeguards and provisions that will be included under their group insurance policy.

The emergency regulation is effective from July 27, 2015, to Oct. 27, 2015, with the expectation of further legislative action.

Title 10 CCR Section 2240 »