Current through Register 2024 Notice Reg. No. 38, September 20, 2024
(a) If an insurer is unable to meet the network
access standard(s) required by this article, the insurer may apply to the
Commissioner for a discretionary waiver of any network access standards and offer an
alternate access delivery system. A waiver application must be resubmitted
annually.
(b) An application for waiver
may only be granted for the following reasons:
(1)
Absence of practicing providers located within sufficient geographic proximity based
upon the time or distance standards of this article.
(2) There are sufficient numbers or types of
providers or facilities in the service area to meet the standards required by this
article, but the insurer demonstrates, through substantial evidence, that, after
good faith efforts, it is unable to contract with sufficient providers or facilities
to meet the network access standards set forth in this article.
(3) An insurer's provider network has been
previously approved under this article, and a provider or facility subsequently
becomes unavailable within the service area.
(4) The application includes a proposal regarding
innovative network design, such as primary care medical homes, "Centers of
Excellence," or accountable care organizations, but only where the innovative
network design is shown to provide a benefit to consumers.
(c) In order for a waiver to be granted, the
insurer must:
(1) Propose an alternate access
delivery system that will provide covered persons with access to medically necessary
care on a reasonable basis without detriment to their health.
(2) Demonstrate that appropriate procedures are in
place to ensure that covered persons obtain all covered services in the alternate
access delivery system, at no greater cost to the covered persons than if the
services were obtained from network providers or facilities. Coinsurance, copayments
and deductible requirements shall apply to alternate access delivery systems at the
same level they are applied to in-network services.
(3) Demonstrate in its alternate access delivery
system proposal a reasonable basis for not meeting any standard set forth in this
Article, and include an explanation of why the proposed alternative access delivery
system provides covered persons with a sufficient number of the appropriate types of
providers or facilities to which the standard in question applies.
(4) Demonstrate in its alternate access delivery
system proposal how the insurer will assist covered persons to locate providers and
facilities in a manner that assures both availability and accessibility.
(A) Covered persons must be able to obtain health
care services from a provider or facility within the closest reasonable proximity of
the covered person in a timely manner appropriate for the covered person's health
needs.
(B) Examples of alternate access
delivery systems include, but are not limited to, such insurer strategies as use of
out-of-county or out-of-service-area providers or facilities, providing regular
scheduled or as-needed transportation from areas within a designated area to those
providers or facilities to ensure that such providers or facilities remain
reasonably accessible, and exceptions to network standards based upon rural
locations in the service area.
(d) The application shall include, at a minimum,
the following:
(1) A description of the affected
area and covered persons in that area and how the insurer determined the absence of
providers or facilities.
(2)
Alternatives that were considered, including but not limited to, telemedicine or
phone consultation.
(3) The applicable
reason or reasons set forth in subdivision (b) of this section.
(4) Any identified issues or risks that may
prevent the alternate access delivery system from providing covered persons with
access to medically necessary care on a reasonable basis without detriment to their
health.
(5) The alternate access
delivery system proposal described, and a description of how the proposed alternate
access delivery system will satisfy the standards set forth in subdivision
(c).
(e) The Commissioner
shall not approve an alternate access delivery system unless:
(1) The insurer provides substantial evidence of
good faith efforts on its part to contract with providers or facilities and can
demonstrate that there is not an available provider or facility with which the
insurer can contract to meet the standards set forth in this article.
(2) The proposed alternate access delivery system
will provide covered persons with access to medically necessary care on a reasonable
basis without detriment to their health.
(f) The Department will post on its Internet Web
site each waiver or alternative access delivery system that the Department approves
under this section on or after June 1, 2016.
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).
Note: Authority cited: Section
10133.5,
Insurance Code. Reference: Sections
10133 and
10133.5,
Insurance Code.
