Current through Register 2024 Notice Reg. No. 38, September 20, 2024
(a) For
all health insurance policies that include the option of utilizing contracted
providers to provide health care services, and specialized health insurance
policies, that provide coverage for the pediatric oral essential health benefit (as
defined in Insurance Code section
10112.27(a)(5)),
the insurer shall file a network adequacy report with the Department, with
accompanying documents, as follows:
(1) Annually on
June 1, a network adequacy report for all health insurance policies providing
current coverage or new health insurance policies.
(2) Upon request by the Commissioner, a network
adequacy report for all health insurance policies providing current coverage or new
health insurance policies.
(3) Whenever
an insurer seeks approval from the department for any policy form that relies upon
or includes the option of utilizing contracted network providers to deliver health
care services, the insurer shall at the same time file a network adequacy report for
the policy form for which approval is sought.
(b) Network adequacy reports, and accompanying
documents, shall be electronically filed with the Health Policy Approval Bureau
through the "California Life & Health" instance of the System for Electronic
Rate and Form Filing (SERFF) of the National Association of Insurance Commissioners
(NAIC).
(c) Network adequacy reports
shall consist of:
(1) A report describing the
number and location of all network providers by county and zip code, including
facilities, primary care providers, specialty providers, mental health providers,
including behavioral health providers, and substance use disorder providers utilized
by the insurer to provide services to covered persons and demonstrating that the
insurer is in compliance with all the accessibility and availability requirements of
these regulations, and identifying the location and extent of areas of
non-compliance.
(2) A description of the
service area covered by the network, by zip code, and describing any change to the
service area since the filing of the most recently filed network adequacy
report.
(d) The following
documents must be submitted with the network adequacy report:
(1) An affidavit or attestation acknowledging
compliance with all the applicable requirements of this regulation.
(2) A copy of the written procedures required by
Section 2240.1(b)(7).
(3) Complete copies, including all appendices,
attachments and exhibits, of the most commonly utilized network provider contracts
for each type of provider the insurer (or its agent if using a leased network)
includes in the provider network, including but not limited to hospital, individual
physician, group physician, laboratory, mental health and substance use disorder
providers, rehabilitation and ancillary service contracts. All material changes to
provider contracts must be filed with the Health Policy Approval Bureau as they
become effective.
(4) Copies of all
written policies and procedures for recruiting network providers, credentialing or
accrediting network providers, contracting with network providers, and managing the
insurer's networks, as required by subdivision (a) of Section
2240.4, including the selection and
tiering standards (if the network is a tiered network) required by subdivision (g)
of Section 2240.1, as well as copies of all
written policies and procedures for the coordination of the transition of an insured
person from an inpatient hospital to an appropriate community setting consistent
with the insured person's post-discharge care needs.
(5) The mental health and substance use disorder
access report required by subdivision (c)(6)(C) of Section
2240.1.
(6) The timely access standards set forth in the
insurer's policies and procedures.
(7) A
report regarding the rate of compliance, during the reporting period, with the time
elapsed standards set forth in Sections
2240.15(b) and
2240.16. An insurer may develop data
regarding rates of compliance through statistically reliable sampling methodology,
including but not limited to provider and insured survey processes.
(8) A report regarding any noncompliance by the
insurer with the provisions of this article. The report shall state whether or not
an incident or pattern described in subdivision (d)(8)(A) or (d)(8)(B) below
occurred during the reporting period and, if so, shall include a description of the
identified non-compliance and the insurer's responsive investigation, determination
and corrective action:
(A) Any incidents of
noncompliance resulting in substantial harm to an insured, or
(B) Any patterns of
non-compliance.
(9) A
description of the implementation and use by the insurer and its contracting
providers of triage, telemedicine, and health information technology to provide
timely access to care.
(10) The results
of the most recent annual covered person and provider surveys required by
subdivisions (c)(2)(B) and (c)(2)(C), respectively, of Section
2240.15 and a comparison with the
results of the prior year's surveys, if any such surveys were conducted, including a
discussion of the relative change in survey results.
(11) Data regarding the extent to which members
used out-of-network services during the reporting period, including the number of
out-of-network claims by type of provider, dollar value of total claims, average
value per claim, total amount paid by the health plan, average amount paid per
claim, total unpaid claim balances and average unpaid claim balance per
claim.
(12) Data regarding the extent to
which members used emergency room services during the reporting period.
(13) The information identifying and providing the
location of each transplant center in the network by name and address, and type of
transplant provided in the facility, required by subdivision (f) of Section
2240.1.
(14) A report describing, for each network
hospital, the percentage of physicians in each of the specialties of (A) emergency
medicine, (B) anesthesiology, (C) radiology, (D) pathology, and (E) neonatology
practicing in the hospital who are in the insurer's network(s).
(15) Information confirming the status of the
insurer's provider network and enrollment at the time of the report, which shall
include, on a county-by-county basis, in a format approved by the Department:
(A) The insurer's enrollment in each product line;
and
(B) A complete list of the insurer's
contracted physicians, hospitals, and other contracted providers, including name,
location, specialty and subspecialty qualifications, California license number and
National Provider Identification Number, as applicable. Physician specialty
designation shall specify board certification or eligibility consistent with the
specialty designations recognized by the American Board of Medical
Specialties.
(e) The
information required by subdivision (d)(15) shall be included with the network
adequacy report until the Department implements a web-based application that
provides for electronic submission via a web portal designated for the collection of
insurer network data. Upon the Department's implementation of the designated network
data collection web portal, the information required by subdivision (d)(15) shall be
submitted directly to the web portal.
(f) An insurer must notify the department
immediately at any time that a material change to any of its networks results in the
insurer being out of compliance with any of the provisions of these regulations and,
at the same time, submit a corrective plan specifying all actions that the insurer
is taking, or will take, to come into compliance with these provisions, and
estimating the time required to do so.
(g) Health insurers that contract for alternative
rates of payment with providers shall annually submit a report to the Department
through the National Association of Insurance Commissioners (NAIC) System for
Electronic Rate and Form Filing (SERFF), no later than March 31, on complaints
received in the previous calendar year by the insurer regarding access to care by
covered persons and issues with contracted providers. This report shall include the
following:
(1) A summary of receipt and resolution
of complaints from covered persons regarding access to or availability of any of the
following services by type of service: primary care services, specialty care
services, mental health or substance use disorder professional services and hospital
services.
(2) A summary of receipt and
resolution of complaints received from providers by network and type of service:
primary care services, specialty care services, mental health or substance use
disorder professional services, hospital services, and other services.
(3) The summaries required by subdivisions (g)(1)
and (g)(2) above shall include the following:
(A)
Total number of complaints in the prior calendar year.
(B) Description of complainant (as consumer,
provider or other).
(C) Status of
complaint as either resolved or unresolved.
(D) Date complaint received.
(E) Time from receipt of the complaint to
resolution of the complaint, if applicable, or a statement that the complaint is
unresolved.
(F) Reason or reasons for
failure to resolve the complaint, if applicable.
(G) Description of complaint resolution, if
applicable.
(h) The
Commissioner may audit compliance with the requirements of this article, and the
accuracy of network adequacy reports and supporting documents submitted pursuant to
this article, including, without limitation, through requests for additional
background information regarding surveys undertaken by an insurer, and through
direct surveys of providers and covered persons.
(i) The department shall review all network
adequacy reports and supporting documents submitted pursuant to this
article.
(j) The department shall review
these complaint reports and any complaints received by the department regarding
timely access to care and shall make this information public, consistent with
applicable law regarding the confidentiality of personally-identifiable
information.
(k) The department's review
of the reports, documents, and data submitted according to the requirements of this
article does not itself act as a waiver of any requirements of this article or of
conflicts with California law regarding a given network's design or
implementation.
1. New section
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
10133 and
10133.5,
Insurance Code.
