Regulations

California Requires Insurers To Have Sufficient Providers

By Robert Sheen | January 06, 2015

California's Commissioner Dave Jones issued an emergency regulation to establish stronger requirements for insurers to maintain sufficient medical provider networks to provide timely access to medical .

CommissionerJones issued the order on Jan. 5, immediately following his inauguration for a second term. He said it was needed to address problems consumers were having getting access to doctors, hospitals, and other medical .

During 2014, he noted, many insurers reduced their medical provider networks and/or shifted to offering Exclusive Provider Organization (EPO) products with no out-- benefits.

Consumers reported having trouble getting appointments with doctors, traveling long distances to receive in- medical , or seeking from doctors who were listed in their insurer's provider directory but who were not actually in the insurer's provider .

The emergency regulation require insurers to:

  • Include enough primary physicians who are accepting new patients to accommodate growth;
  • Include enough primary and specialists with privileges at hospitals;
  • Consider the demand for mental and substance abuse when creating their provider ;
  • Monitor appointment wait times;
  • Report changes to their networks to the Department ;
  • Provide accurate provider directories to the Department, policyholders and the public;
  • Provide out-- at in- prices when there are insufficient in- ;
  • Require facilities to inform patients in advance if an out-- provider will participate in a non-emergency procedure, so the patient can decline the services the out-- provider if they choose.

The emergency regulation will be noticed and then filed with the Administrative Law (OAL) and go into effect upon OAL's completion its review.

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