Network Regs Go Into Effect Immediately

Emergency regulations go into effect immediately to establish stronger requirements for health insurers to create and maintain medical provider networks. In 2014, 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 said they had trouble getting appointments with doctors; they had to go long distances to get in-network medical care; or they went to doctors who appeared in their health insurer’s provider directory, but were not in the health insurer’s medical provider network.

California Insurance Commissioner Dave Jones said, “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.”

The emergency regulations require health insurers to do the following:
• Include enough primary care physicians who accept new patients in order to accommodate enrollment growth.
• Include enough primary care providers and specialists with admitting and practice privileges at network hospitals.
• Consider the frequency and type of treatment that’s 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 Dept. of Insurance on an ongoing basis.
• Provide accurate provider network directories to the Department and make them available to policyholders and the public.
• Make arrangements to provide out-of-network care at in-network prices when there are insufficient in-network care providers.

Last Updated 01/19/2022

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