CA: Insurance Commissioner limits narrow networks with emergency rule

The California Department of Insurance (CDI) Commissioner Dave Jones issued an emergency regulation on Dec. 5 to address consumer complaints regarding narrow provider networks. The rule will set new standards on appointment wait times and adequate number of network physicians. Changes are pending review by the Office of Administrative Law and will give Jones power to bar insurers from selling insurance in the state next year if they do not comply with regulation.

The CDI reports that it has received continued complaints from consumers about carriers misrepresenting the size of their provider networks. The office reports evidence that insurers are providing an inaccurate directory of providers and charging out-of-network costs while offering no in-network physician options. Long appointment wait times are also a chief consumer concern, according to Jones in a statement to Capital Public Radio.

The new emergency regulation, which Jones issued immediately after being sworn-in to his second term, puts stricter much limitations on narrow networks. If passed, all California health insurers will be required to demonstrate the following:

-Include an adequate number of primary care physicians in their network that accommodates current and anticipated enrollment growth.
-Adhere to and monitor new appointment wait time standards set by the CDI.
-Report information on network changes on an ongoing basis to the CDI
-Consider mental health and substance abuse treatment when creating provider network
-Provide out-of-network care at the same price as in-network services when insufficient in-network care is available
-Require facilities to inform patients that their non-emergency procedure is out-of-network so that they may decline the provider if they choose

The CDI has been involved in public disputes and legal action against several California health insurers, most notably Anthem BlueShield, throughout 2014. Jones renews his offensive stance in 2015.

“Californians and California businesses deserve better than what they have gotten from most health insurers and HMOs,” said Jones in a prepared statement. “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 policy holders, 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 the patients’ consent or foreknowledge.”

The office reports that it anticipates a short review as emergency regulations often take effect more quickly than standard regulations.