Commissioner Dave Jones Issues Emergency Regulation Requiring Health Insurers to Have Sufficient Medical Providers

At his inauguration ceremony today and immediately after he was sworn-in for a second term, California’s Insurance Commissioner Dave Jones issued an emergency regulation to establish stronger requirements for health insurers to create and maintain sufficient medical provider networks to provide timely access to medical care.

The emergency regulation issued today by Commissioner Jones today at his inauguration ceremony addresses the problems identified with access to doctors, hospitals, and other medical providers in 2014, as many health insurers reduced their medical provider networks and/or shifted to offering Exclusive Provider Organization (EPO) health insurance products with no out-of-network benefits. Consumers complained of having trouble getting appointments with doctors, traveling long distances to receive in-network medical care, or seeking care from doctors who appeared in their health insurer’s provider directory but who were not actually in the health insurer’s medical provider network.

“Californians and California businesses deserve better than what they have gotten from most health insurers and HMOs. Health insurers’ medical provider directories have been inaccurate, misleading consumers into signing up with a health insurer for access to a doctor, specialist, or hospital only to learn that these medical providers are not actually a part of the health insurer’s network. 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,” said Commissioner Jones. “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 the patients’ consent or foreknowledge.”

“I am grateful to the voters of California for electing me to serve a second term as Insurance Commissioner,” said Jones after being sworn-in. “As was my first term, my second term will be one of action on behalf of consumers. In keeping with my commitment to take action to protect consumers, just minutes after being sworn-in I am issuing an emergency regulation to protect consumers from health insurers with inadequate networks of medical providers.”

The Commissioner’s emergency regulation strengthens and adds new medical provider network requirements, including requiring 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.

The emergency regulation will be noticed and then filed with the Office of Administrative Law (OAL) and go into effect upon OAL’s completion of its review. By law, emergency regulations go into effect more quickly than regular regulations.

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