The regulator of the nation's largest state market is taking a proactive, interventionist stance on the still fractious issue of network adequacy.
In tandem with Dave Jones' inauguration to a second term as California insurance commissioner, he released new emergency regulations for health plan provider networks -- the emergency designation giving the proposals an expeditious path to codification in state law.
"Californians and California businesses deserve better than what they have gotten from most health insurers and HMOs," Jones said. "Health insurers' medical provider directories have been inaccurate, misleading consumers into signing up with a health insurer for access to a doctor, specialist, or hospital only to learn that these medical providers are not actually a part of the health insurer's network."
As proposed in a summary, the regulations cover eight aspects of provider networks in individual and small group health plans.
Health plans would be required to include "an adequate number of primary care physicians accepting new patients to accommodate recent and ongoing anticipated enrollment growth," and an adequate number of PCPs and specialists with admitting privileges at network hospitals. (Adequacy is not defined in the summary; the full regulatory proposal has yet to be filed with the California Office of Administrative Law.)
In designing new networks, health plans would have to consider "the frequency and type of treatment needed to provide mental health and substance use disorder care."
They would have to share provider network with the Department of Insurance and make them available to both members and the general public, secure arrangements for coverage of out-of-network care at in-network costs for members when in-network provider access is insufficient, and require network providers to inform members about whether a non-network provider is participating in any non-emergency service, "so that the patient can decline the participation of the out-of-network provider if they so choose." Health plans would also have to adhere to and monitor new (though unspecified) appointment wait time standards.
Since being elected to insurance commissioner in 2010, Jones has aggressively pursued what he sees as a health insurance industry too focused on profits. Though he was re-elected last November, a ballot proposition he campaigned for failed.
The Insurance Rate Public Justification and Accountability Act would have empowered Jones and future California insurance commissioners to review and veto individual and small group health plan premiums. Jones called the rate review idea the "missing piece" of the Affordable Care Act, although leaders at the state insurance exchange, Covered California, did not support the measure and the health insurance industry, hospital and physicians groups waged a public campaign against it.
Another state agency, the Department of Managed Health Care actually oversees more than 90 percent of health coverage in California, covering all HMOs and most PPos. The DMHC "already has robust network adequacy requirements in place," the Nicole Evans, spokesperson for the California Association of Health Plans said.
For exchange plans, Evans said, the Deptartment of Insurance has jurisdiction over just only two percent of Covered California's enrollment, representing some of the PPOs.
Nonetheless, Jones said he wants to address consumer concerns with health insurance, if not in the premiums or in all the plans, then in the benefits for those he oversees -- a pursuit that could put the commissioner at odds with Covered California's "active purchaser" strategy.
The emergency regulations, Jones said, are "necessary to make sure that health insurers establish and maintain adequate medical provider networks to meet the healthcare needs of their policyholders, to make sure medical provider directories are accurate, and to stop the practice of surprising consumers with huge charges for out-of-network providers who provide care without the patients' consent or foreknowledge."