On January 5, 2015, Commissioner Dave Jones issued emergency regulations affecting health insurers with respect to access to provider networks in response to consumer complaints that appointments with physicians are hard to obtain, that in-network care is far away, and that in-network provider directories are inaccurate.

The emergency regulation will require 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;
  • 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.

These new requirements may require insurers to commit additional resources into monitoring their networks, and failure to adhere to these requirements could result in a bar from selling insurance in California in 2016.  The full details of this regulation will be filed with the Office of Administrative Law, and go into effect shortly thereafter.