CHA News Article

CDI Issues Permanent Regulations on Network Adequacy
Regulations effective immediately

The California Department of Insurance (CDI) has issued permanent regulations on provider network adequacy that go into effect immediately. The regulations were approved by the Office of Administrative Law and replace the emergency regulations issued in January 2015. The new network adequacy regulations will apply to insurers regulated by the CDI. Plans regulated by the Department of Managed Health Care — typically health care plans such as HMOs and some PPOs — are subject to different network adequacy laws and regulations.

CDI’s goal for the regulations is ensuring consumers have access to sufficient numbers and types of health care providers and limiting the “surprise bill” effect (from out-of-network providers) by setting minimum standards for health insurers’ provider networks. Insurers will be required to pay for out-of-network care if patients cannot secure medically necessary services within their health plan’s network. Otherwise, the network will be deemed inadequate. 

Insurers will also be required to include a sufficient number of primary care and specialty providers in their network; adhere to and monitor appointment wait time standards; maintain accurate provider directories and update them weekly; and regularly report network changes to CDI, among other requirements. Adequate network requirements for post-acute care and mental health are also included.

Commands