California Code of Regulations
Title 10 - Investment
Chapter 5 - Insurance Commissioner
Subchapter 2 - Policy Forms and Other Documents
Article 6 - Provider Network Access Standards for Health Insurance
Section 2240.15 - Network Access Appointment Waiting Time Standards; Quality Assurance; Disclosure and Education
Universal Citation: 10 CA Code of Regs 2240.15
Current through Register 2024 Notice Reg. No. 38, September 20, 2024
(a) For purposes of this section, the following definitions apply:
(1) "Appointment waiting time" means the time from
the initial request for health care services by a covered person or the covered
person's treating provider to the earliest date offered for the appointment for
services, inclusive of time for obtaining authorization from the insurer or
completing any other condition or requirement of the insurer or its contracting
providers.
(2) "Preventive care" means
health care provided for prevention and early detection of disease, illness, injury
or other health condition and, in the case of an insurer includes but is not limited
to all of the services required by Insurance Code section
10112.2
(incorporating the requirements of
42 United States Code §
300gg-13 (Public Health Service Act §
2713), and 45 Code of Federal
Regulations § 146.130) and subdivision (a)(2)(A)(ii) of section
10112.27 of the
Insurance Code.
(3) "Provider group" has
the meaning set forth in subdivision (g)(3) of section
10133.56 of the
Insurance Code.
(4) "Triage" or
"screening" means the assessment of a covered person's health concerns and symptoms
via communication with a physician, registered nurse, or other qualified health
professional acting within the physician, registered nurse, or other qualified
health professional's scope of practice and who is trained to screen or triage an
insured who may need care, for the purpose of determining the urgency of the covered
person's need for care.
(5) "Triage or
screening waiting time" means the time waiting to speak by telephone with a
physician, registered nurse, or other qualified health professional acting within
the physician, registered nurse, or other qualified health professional's scope of
practice and who is trained to screen or triage an insured who may need
care.
(6) "Urgent care" means health
care for a condition that requires prompt attention, consistent with subdivision
(h)(2) of section
10123.135 of the
Insurance Code.
(b) Standards for Timely Access to Care.
(1) Insurers shall
provide or arrange for the provision of covered health care services in a timely
manner appropriate for the nature of the covered person's condition consistent with
good professional practice. Insurers shall establish and maintain provider networks,
policies, procedures and quality assurance monitoring systems and processes
sufficient to ensure compliance with this clinical appropriateness standard. An
insurer that uses a tiered network must demonstrate compliance with the standards
established by this section based on providers available at the lowest cost-sharing
tier.
(2) Insurers shall ensure that all
network and provider processes necessary to obtain covered health care services,
including but not limited to prior authorization processes, are completed in a
manner that assures the provision of covered health care services to covered persons
in a timely manner appropriate for the covered person's condition and in compliance
with the requirements of this section.
(3) When it is necessary for a provider or a
covered person to reschedule an appointment, the appointment shall be promptly
rescheduled in a manner that is appropriate for the covered person's health care
needs, and ensures continuity of care consistent with good professional practice,
and consistent with the objectives of Section
10133.5 of the
Insurance Code and the requirements of this section.
(4) Interpreter services required by Section
10133.8 of the
Insurance Code and Article 12 of Title 10 California Code of Regulations, commencing
with Section 2538.1, shall be coordinated with
scheduled appointments for health care services in a manner that ensures the
provision of interpreter services at the time of the appointment consistent with
Title 10, California Code of Regulations, section
2538.6 without imposing delay on the
scheduling of the appointment. This subdivision (b)(4) does not modify the
requirements established in sections
10133.8 or
10133.9 of the
Insurance Code.
(5) In addition to
ensuring compliance with the clinical appropriateness standard set forth at
subdivision (b)(1), each insurer shall ensure that its contracted provider network
has adequate capacity and availability of licensed health care providers to offer
covered persons appointments that meet the following timeframes:
(A) Urgent care appointments for services that do
not require prior authorization: within 48 hours of the request for appointment,
except as provided in subdivision (b)(5)(G);
(B) Urgent care appointments for services that
require prior authorization: within 96 hours of the request for appointment, except
as provided in subdivision (b)(5)(G);
(C) Non-urgent appointments for primary care:
within ten business days of the request for appointment, except as provided in
subdivisions (b)(5)(G) and (b)(5)(H);
(D) Non-urgent appointments with specialist
physicians: within fifteen business days of the request for appointment, except as
provided in subdivisions (b)(5)(G) and (b)(5)(H);
(E) Non-urgent appointments with a non-physician
mental health care or substance use disorder provider: within ten business days of
the request for appointment, except as provided in subdivisions (b)(5)(G) and
(b)(5)(H);
(F) Non-urgent appointments
for ancillary services for the diagnosis or treatment of injury, illness, or other
health condition: within fifteen business days of the request for appointment,
except as provided in subdivisions (b)(5)(G) and (b)(5)(H);
(G) The applicable waiting time for a particular
appointment may be extended if the referring or treating licensed health care
provider, or the health professional providing triage or screening services, as
applicable, acting within the scope of the practice of the licensed health care
provider or the health professional providing triage or screen services and
consistent with professionally recognized standards of practice, has determined and
noted in the relevant record that a longer waiting time will not have a detrimental
impact on the health of the covered person;
(H) Preventive care services, as defined at
subdivision (a)(2), and periodic follow up care, including but not limited to,
standing referrals to specialists for chronic conditions, periodic office visits to
monitor and treat pregnancy, cardiac or mental health or substance use disorder
conditions, and laboratory and radiological monitoring for recurrence of disease,
may be scheduled in advance consistent with professionally recognized standards of
practice as determined by the treating licensed health care provider acting within
the scope of the treating licensed health care provider's
practice.
(6) Insurers shall
ensure they have sufficient numbers of contracted providers to maintain compliance
with the standards established by this section. This section does not modify the
requirements regarding provider adequacy and accessibility established by this
Article.
(7) Insurers shall provide or
arrange for the provision, 24 hours per day, 7 days per week, of triage or screening
services by telephone as defined in subdivision (a)(5).
(A) Insurers shall ensure that telephone triage or
screening services are provided in a timely manner appropriate for the insured's
condition, and that the triage or screening waiting time does not exceed 30
minutes.
(B) An insurer may provide or
arrange for the provision of telephone triage or screening services through one or
more of the following means: insurer-operated telephone triage or screening services
consistent with subdivision (a)(5); telephone medical advice services pursuant to
Section
10279 of the
Insurance Code; the insurer's contracted primary care and mental health care or
substance use disorder provider network; or other method that provides triage or
screening services consistent with the requirements of this subdivision
(b)(7)(B).
(8) An insurer that
arranges for the provision of telephone triage or screening services through
contracted primary care, mental health care, and substance use disorder providers
shall require those providers to maintain a procedure for triaging or screening
covered persons' telephone calls, which, at a minimum, shall include the employment,
during and after business hours, of a telephone answering machine and/or an
answering service and/or office staff, that will inform the caller:
(A) Regarding the length of wait for a return call
from the provider; and
(B) How the
caller may obtain urgent or emergency care including, when applicable, how to
contact another provider who has agreed to be on-call to triage or screen by phone,
or if needed, deliver urgent or emergency care.
(9) An insurer that arranges for the provision of
triage or screening services through contracted primary care, mental health care,
and substance use disorder providers who are unable to meet the time-elapsed
standards established in paragraph (b)(7)(A) shall also provide or arrange for the
provision of insurer-contracted or operated triage or screening services, which
shall, at a minimum, be made available to covered persons affected by that portion
of the insurer's network.
(10)
Unlicensed staff persons handling covered person calls may ask questions on behalf
of a licensed staff person in order to help ascertain the condition of a covered
person so that the covered person can be referred to licensed staff. However, under
no circumstances shall unlicensed staff persons use the answers to those questions
in an attempt to assess, evaluate, advise, or make any decision regarding the
condition of a covered person or determine when a covered person needs to be seen by
a licensed medical professional.
(11)
Insurers shall ensure that, during normal business hours, the waiting time for a
covered person to speak by telephone with an insurer customer service representative
knowledgeable and competent regarding the covered person's questions and concerns
shall not exceed ten (10) minutes, or that the covered person will receive a
scheduled call-back within 30 minutes.
(12) For health insurance policies providing
coverage for the pediatric oral and vision essential health benefit, and specialized
health insurance policies that provide coverage for dental care expenses only,
insurers shall require that contracted providers employ an answering service or a
telephone answering machine during non-business hours which provides instructions
regarding how covered persons may obtain urgent or emergency care including, when
applicable, how to contact another provider who has agreed to be on-call to triage
or screen by phone or, if needed, deliver urgent or emergency
care.
(c) Quality Assurance Processes. Each insurer shall have written quality assurance systems, policies and procedures designed to ensure that the insurer's provider network is sufficient to provide accessibility, availability and continuity of covered health care services as required by the Insurance Code and this section. An insurer's quality assurance program shall address:
(1) Standards for the
provision of covered services in a timely manner consistent with the requirements of
this section and Section
2240.16.
(2) Compliance monitoring policies and procedures,
filed for the Commissioner's review and approval, designed to accurately measure the
accessibility and availability of contracted providers, which shall include:
(A) Tracking and documenting network capacity and
availability with respect to the standards set forth in, subdivision (b) of this
Section 2240.15, and Section
2240.16; and
(B) Conducting an annual covered person experience
survey, which shall be conducted in accordance with valid and reliable survey
methodology and designed to ascertain compliance with the standards set forth in
subdivision (b) of this section; however, for health insurance policies that provide
coverage for the pediatric vision or oral essential health benefit and for
specialized health insurance policies that provide coverage for the pediatric oral
essential health benefit (as defined in subdivision (a)(5) of Insurance Code section
10112.27), the
survey shall be designed to ascertain compliance with the standards set forth in
Section 2240.16. The Department will make the
aggregated results of this survey publicly available; and
(C) Conducting an annual provider survey, which
shall be conducted in accordance with valid and reliable survey methodology and
designed to solicit, from physicians and non-physician mental health and substance
use disorder providers, perspectives and concerns regarding compliance with the
standards set forth at subdivision (b) of this section; however, for health
insurance policies that provide coverage for the pediatric vision or oral essential
health benefit, and for specialized health insurance policies that provide coverage
for the pediatric oral essential health benefit (as defined in subdivision (a)(5) of
Insurance Code section
10112.27), the
survey shall be designed to solicit perspectives and concerns from providers
regarding compliance with the standards set forth in Section
2240.16. The Department will make the
results of this survey publicly available; and
(D) Reviewing and evaluating, no less frequently
than quarterly, the information available to the insurer regarding accessibility,
availability and continuity of care, including but not limited to information
obtained through covered person and provider surveys, covered person grievances and
appeals, and triage or screening services.
(3) An insurer shall implement prompt
investigation and corrective action when compliance monitoring discloses that the
insurer's provider network is not sufficient to ensure timely access as required by
this section, including but not limited to taking all necessary and appropriate
action to identify the cause(s) underlying identified timely access deficiencies and
to bring its network into compliance. Insurers shall give advance written notice to
all contracted providers affected by a corrective action, and shall include: a
description of the identified deficiencies, the rationale for the corrective action,
and the name and telephone number of the person authorized to respond to provider
concerns regarding the insurer's corrective action.
(d) Disclosure and Education.
(1) Insurers shall disclose in all policies,
certificates, and coverage materials the availability of triage or screening
services and how to obtain those services. Insurers shall disclose annually, in
insurer newsletters or comparable communications to covered persons, the
Department's standards for timely access, the insurer's process for ensuring timely
access, and what steps a covered person should take when experiencing access
problems inconsistent with timely access standards, including when and how to access
applicable Department and insurer helplines.
(2) The telephone number at which covered persons
can access triage and screening services shall be included on covered person
membership cards. An insurer may comply with this requirement through an additional
selection in its automated customer service telephone answering system, where
applicable, provided that the customer service number is included on the covered
person's membership card.
1. New section
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.
2.
New section 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.
3. New section 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.
4. Certificate of Compliance as to 10-26-2015 order,
including 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).
5. Change without regulatory effect amending
subsections (a)(4)-(5) and (b)(5)(G)-(H) filed 7-14-2021 pursuant to section
100, title 1, California Code of
Regulations (Register 2021, No. 29). Filing deadline specified in Government Code
section
11349.3(a)
extended 60 calendar days pursuant to Executive Order
N-40-20.
Note: Authority cited: Section 10133.5, Insurance Code. Reference: Sections 106(b), 10133, 10133.5 and 10133.8, Insurance Code.
Disclaimer: These regulations may not be the most recent version. California may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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