Current through Register 2024 Notice Reg. No. 38, September 20, 2024
(a) The provisions of this article apply to
"health insurance" policies as defined by Insurance Code section
106(b).
The requirements of this article apply to all health care services covered by the
insurance policy. Notwithstanding the above, specialized health insurance policies
as defined in Insurance Code section
106(c),
other than specialized mental health insurance policies, are exempt from the
provisions of this article, except as specified below, in subdivisions (a)(1),
(a)(2), and (a)(3) of this Section
2240.1:
(1) Specialized health insurance policies that
provide coverage for dental care expenses only shall comply with the following:
(A) Subdivisions (b)(7) and (e) of Section
2240.1,
(B) Subdivisions (b)(1), (b)(3), (b)(4), (b)(6),
(b)(11), (b)(12), and (c)(1) of Section
2240.15,
(C) Section
2240.16, and
(D) Section
2240.3;
(2) Specialized health insurance policies that
provide coverage for the pediatric oral essential health benefit (as defined in
Insurance Code section
10112.27(a)(5)),
including but not limited to such policies sold through the California Health
Benefit Exchange, shall comply with the following:
(A) Subdivisions (c)(2) and (c)(4) of Section
2240.1,
(B) Subdivisions (c)(2) and (c)(3) of Section
2240.15,
(C) Subdivision (a) of Section
2240.4,
(D) Subdivisions (a), (b), (c), (d)(1), (d)(2),
(d)(3), (d)(4), (d)(6), (d)(7), (d)(8), (d)(10), (d)(11), (d)(15), (e), and (f) of
Section 2240.5, and
(E) Section
2240.7;
(3) Insurers that issue specialized health
insurance policies other than specialized mental health insurance policies shall
comply with subdivision (h) of Section
2240.6;
(4) For purposes of this subdivision (a), the term
"specialized mental health insurance policies" includes behavioral health-only
policies.
(b) In arranging for
network provider services, insurers shall ensure that:
(1) Network providers are duly licensed or
accredited and that they are sufficient in number, capacity, and specialty to be
capable of furnishing the health care services covered by the insurance contract,
taking into account the number of covered persons, their characteristics and medical
needs including the frequency of accessing needed medical care within the prescribed
geographic distances outlined herein and the projected demand for services by type
of services. If a network provider does not provide a service otherwise within the
provider's scope of practice covered under the insurance contract, the insurer shall
ensure that there are sufficient providers in the network to provide that service.
Subdivision (e) of this section shall apply if no providers in the network provide
that service.
(2) Decisions pertaining
to health care services to be rendered by providers to covered persons are based on
such persons' medical needs and are made by or under the supervision of licensed and
appropriate health care professionals.
(3) Facilities used by providers to render health
care services are located within reasonable proximity to the work places or the
principal residences of the primary covered persons, are reasonably accessible by
public transportation and are reasonably accessible, both physically and in terms of
provision of service, to covered persons with disabilities. Insurers shall establish
written standards for their providers that ensure that provider facilities are
accessible to people with disabilities and compliant with all applicable state and
federal laws regarding access for people with disabilities.
(4) Health care services (excluding emergency
health care services) are available at least 40 hours per week, except for weeks
including holidays. Such services shall be available until at least 10:00 p.m. at
least one day per week or for at least four hours each Saturday, except for
Saturdays falling on holidays.
(5)
Emergency health care services are available and accessible within the service area
at all times.
(6) Health care services
are accessible to covered persons through network providers, or other network
arrangement. An adequate network is one in which the care provided to an insured
person in a network facility is provided by network providers. The provision of care
by an out-of-network provider to an insured person in a network facility renders the
network inadequate unless:
(A) the insured person,
without being prompted to do so, has initiated a request to receive care from that
specific out-of-network provider; or
(B)
coverage is provided on terms no less favorable, and at no greater cost, to the
insured person than would have applied had the care been provided by an in-network
provider.
(7) Network provider
services are rendered pursuant to written procedures which include a documented
system for monitoring and evaluating accessibility of such care. The monitoring of
waiting time for appointments, as described in Sections
2240.15 and
2240.16, shall be a part of such a
system.
(c) In arranging for
network provider services, insurers shall ensure that, for current insured
membership and anticipated enrollment growth for the year following the network
report:
(1) There is the equivalent of at least
one full-time physician per 1,200 covered persons and at least the equivalent of one
full-time primary care physician per 2,000 covered persons.
(2) There are primary care network providers with
sufficient capacity to accept covered persons within a maximum travel time of 30
minutes or a maximum travel distance of 15 miles of each covered person's residence
or workplace.
(3) There are adequate
full-time equivalents of primary care and specialist providers in the network
accepting new patients covered by the policy to accommodate anticipated enrollment
growth.
(4) There are medically required
network specialists who are certified or eligible for certification by the
appropriate specialty board with sufficient capacity to accept covered persons
within a maximum travel time of 60 minutes or a maximum travel distance of 30 miles
of each covered person's residence or workplace.
(5) Notwithstanding the above, the Commissioner
may determine that certain medical needs require network specialty care located
closer to covered persons when the nature and frequency of use of such health care
services, and the standards of Insurance Code 10133.5(b) (3), support such
modification.
(6) There are mental
health and substance use disorder professionals with skills appropriate to care for
the mental health and substance use disorder needs of covered persons and with
sufficient capacity to accept covered persons within a maximum travel time of 30
minutes or a maximum travel distance of 15 miles of each covered person's residence
or workplace. The network must adequately provide for mental health and substance
use disorder treatment, including behavioral health therapy. The network must take
into account the pattern and frequency with which different therapies, particularly
behavioral health therapy, are provided for different patient populations at
different ages, such that if it is clinically necessary for a network to have
services available in closer proximity to affected covered persons than required by
the minimum time and proximity standards stated above then the insurer shall make
the services available in such closer proximity.
(A) Adequate networks include crisis intervention
and stabilization, psychiatric inpatient hospital services, including voluntary
psychiatric inpatient services, detoxification, outpatient mental health and
substance use evaluation and treatment, psychological testing, outpatient services
for monitoring drug therapy, partial hospitalization, intensive outpatient
treatment, short-term treatment in a crisis residential program in a licensed
psychiatric treatment facility with 24-hour monitoring by clinical staff for
stabilization of an acute psychiatric crisis, psychiatric observation for an acute
psychiatric crisis and services from mental health providers. Networks must also
provide for the diagnosis and medically necessary treatment of severe mental
illnesses of a person of any age, and of serious emotional disturbances of a child,
including residential care.
There must be mental health and substance use disorder providers
of sufficient number and type to provide diagnosis and medically necessary treatment
through providers acting within their scope of license and scope of competence
established by education, training, and experience to diagnose and treat mental
health and substance use disorders.
(B) An insurer must establish a reasonable
standard approved by the Department for the number and geographic distribution of
mental health providers who can treat severe mental illness of a person of any age
and serious emotional disturbances of a child, taking into account the various types
of mental health practitioners acting within the scope of their licensure, and those
practitioners described in subdivision (c) of section
10144.51 of the
Insurance Code.
(C) The insurer must
submit a narrative report describing the adequacy of its mental health and substance
use disorder network to the Department for approval no less frequently than annually
as part of the network adequacy report required by Section
2240.5.
(D) An insurer must include a sufficient number of
the appropriate types of mental health and substance use disorder treatment
providers and facilities based on normal utilization patterns.
(E) An insurer must ensure that covered persons
can access information about mental health and substance use disorder services,
including benefits, providers, coverage, and other relevant information, by calling
a customer service representative, or otherwise contacting the company through an
accessible means, during normal business hours.
(7) There is a network hospital with sufficient
capacity to accept covered persons for covered services within a maximum travel time
of 30 minutes or a maximum travel distance of 15 miles of each covered person's
residence or workplace. Networks must include hospitals with sufficient capacity to
serve the entire population of covered persons based on normal utilization
patterns.
(8) The network includes
adequate numbers of available primary care providers and specialists with admitting
and practice privileges at network hospitals.
(9) The network includes facilities to provide
post-acute care services with sufficient capacity to serve the entire population of
covered persons based on normal utilization patterns.
(10) The network includes an adequate number of
network outpatient retail pharmacies located in sufficient proximity to covered
persons to permit adequate routine and emergency access. Similarly, ancillary
laboratory and other services dispensed by order or prescription of the prescribing
provider are available from contracting providers at locations (where covered
persons are personally served) within a reasonable distance from the prescribing
provider.
(d) Networks shall
be designed to optimize access by using a variety of facility types, such as
ambulatory surgical centers. Further, access to facilities, such as dialysis
centers, shall be designed to accommodate the intensity and frequency of use by the
patient population.
(e) Networks must
provide access to medically appropriate care from a qualified provider. If medically
appropriate care cannot be provided within the network, the insurer shall arrange
for the required care with available and accessible providers outside the network,
with the patient responsible for paying only cost-sharing in an amount equal to the
cost-sharing they would have paid for provision of that or a similar service
in-network. In addition to in-network copayments and coinsurance, in-network cost
sharing includes applicability of the in-network deductible and accrual of cost
sharing to the in-network out-of-pocket maximum.
(f) An adequate network must also demonstrate the
capacity to provide medically necessary organ, tissue, and stem cell transplant
surgery. The insurer in its network adequacy report required by Section
2240.5 shall identify and locate each
transplant center in its network by name and address, and type of transplant
provided in the facility.
(g) An
adequate network must include a sufficient number of providers to assure access to
preventive services required by Insurance Code section
10112.2,
including women's preventive care, which includes access to services and
contraceptive methods as required by Insurance Code section
10123.196.
(h) A service area or network must not be created
in a manner designed to discriminate or that results in discrimination against
persons because of age, gender, actual or perceived gender identity as defined in
Section 2561.1 or on the basis that the insured
is a transgender person as defined in Section
2561.1, sexual orientation, disability,
national origin, sex, family structure, ethnicity, race, color, ancestry, religion,
utilization of medical or mental health or substance use disorder services or
supplies, marital status, health insurance coverage, present or predicted
disability, expected length of life, degree of medical dependency, quality of life,
health status or medical condition, including physical and mental illnesses, claims
experience, medical history, genetic information, or evidence of insurability,
including conditions arising out of domestic violence.
(i) Health carrier standards for the selection and
tiering (if the network is a tiered network) of participating providers and
facilities shall be developed for primary care professionals and each health care
professional specialty and facility, shall include measures related to standards for
quality of care and health outcomes, and shall be provided to the Department no less
frequently than annually as part of the network adequacy report required by Section
2240.5. The standards shall be used in
determining the selection of health care professionals and facilities by the health
carrier, its intermediaries and any provider networks with which it contracts.
Selection criteria shall not be established in a manner:
(1) That would allow a health carrier to avoid
high-risk populations by excluding providers because they are located in geographic
areas that contain populations or providers presenting a risk of higher than average
claims, losses or health services utilization; or
(2) That would exclude providers because they
treat or specialize in treating populations presenting a risk of higher than average
claims, losses or health services utilization.
(j) Networks for mountainous rural areas shall
take into consideration typical patterns of winter road closures, so as to comply
with access and timeliness standards throughout the calendar year.
(k) An insurer that uses a tiered network shall
meet the standards of this article using the providers available at the lowest
cost-sharing tier.
(l) The insurer must
measure the adequacy of its network at least every six months, and demonstrate and
attest to the Department that it has done so, and submit a corrective action plan to
the Commissioner if the standards set forth in this article are not met.
(m) Notwithstanding the above, the Commissioner
may determine that certain medical needs require network providers and/or facilities
located closer to covered persons when the nature and frequency of use of such
health care services, and the standards of Insurance Code section
10133.5(b)
(3), support such modification.
(n) Notwithstanding the above, these requirements
are not intended to prevent the covered person from selecting providers as allowed
by their insurance contract beyond the applicable geographic area specified by these
standards.
(o) In determining whether an
insurer's arrangements for network provider services comply with these regulations,
the Commissioner shall consider to the extent the Commissioner deems necessary, the
practices of comparable health care service plans licensed under the Knox-Keene
Health Care Service Plan Act of 1975 Health and Safety Code Section
1340, et
seq.
1. Amendment of
section heading, section and NOTE filed 1-8-2008; operative 2-7-2008 (Register 2008,
No. 2).
2. Amendment filed 1-30-2015 as an emergency; operative 1-30-2015
(Register 2015, No. 5). A Certificate of Compliance must be transmitted to OAL by
7-29-2015 or emergency language will be repealed by operation of law on the
following day.
3. Amendment refiled 7-27-2015 as an emergency; operative
7-27-2015 (Register 2015, No. 31). A Certificate of Compliance must be transmitted
to OAL by 10-26-2015 or emergency language will be repealed by operation of law on
the following day.
4. Amendment refiled 10-26-2015 as an emergency;
operative 10-26-2015 (Register 2015, No. 44). A Certificate of Compliance must be
transmitted to OAL by 1-25-2016 or emergency language will be repealed by operation
of law on the following day.
5. Certificate of Compliance as to
10-26-2015 order, including further amendment of section, transmitted to OAL
1-25-2016 and filed 3-8-2016; amendments operative 3-8-2016 pursuant to Government
Code section
11343.4(b)(3)
(Register 2016, No. 11).
Note: Authority cited: Section
10133.5,
Insurance Code. Reference: Sections
106(b),
10133 and
10133.5,
Insurance Code.
