Section 2240.1 - Adequacy and Accessibility of Provider Services(a) The provisions of this article apply to "health insurance" policies as defined by Insurance Code section 106(b). The requirements of this article apply to all health care services covered by the insurance policy. Notwithstanding the above, specialized health insurance policies as defined in Insurance Code section 106(c), other than specialized mental health insurance policies, are exempt from the provisions of this article, except as specified below, in subdivisions (a)(1), (a)(2), and (a)(3) of this Section 2240.1: (1) Specialized health insurance policies that provide coverage for dental care expenses only shall comply with the following:(A) Subdivisions (b)(7) and (e) of Section 2240.1,(B) Subdivisions (b)(1), (b)(3), (b)(4), (b)(6), (b)(11), (b)(12), and (c)(1) of Section 2240.15,(2) Specialized health insurance policies that provide coverage for the pediatric oral essential health benefit (as defined in Insurance Code section 10112.27(a)(5)), including but not limited to such policies sold through the California Health Benefit Exchange, shall comply with the following: (A) Subdivisions (c)(2) and (c)(4) of Section 2240.1,(B) Subdivisions (c)(2) and (c)(3) of Section 2240.15,(C) Subdivision (a) of Section 2240.4,(D) Subdivisions (a), (b), (c), (d)(1), (d)(2), (d)(3), (d)(4), (d)(6), (d)(7), (d)(8), (d)(10), (d)(11), (d)(15), (e), and (f) of Section 2240.5, and(3) Insurers that issue specialized health insurance policies other than specialized mental health insurance policies shall comply with subdivision (h) of Section 2240.6;(4) For purposes of this subdivision (a), the term "specialized mental health insurance policies" includes behavioral health-only policies.(b) In arranging for network provider services, insurers shall ensure that: (1) Network providers are duly licensed or accredited and that they are sufficient in number, capacity, and specialty to be capable of furnishing the health care services covered by the insurance contract, taking into account the number of covered persons, their characteristics and medical needs including the frequency of accessing needed medical care within the prescribed geographic distances outlined herein and the projected demand for services by type of services. If a network provider does not provide a service otherwise within the provider's scope of practice covered under the insurance contract, the insurer shall ensure that there are sufficient providers in the network to provide that service. Subdivision (e) of this section shall apply if no providers in the network provide that service.(2) Decisions pertaining to health care services to be rendered by providers to covered persons are based on such persons' medical needs and are made by or under the supervision of licensed and appropriate health care professionals.(3) Facilities used by providers to render health care services are located within reasonable proximity to the work places or the principal residences of the primary covered persons, are reasonably accessible by public transportation and are reasonably accessible, both physically and in terms of provision of service, to covered persons with disabilities. Insurers shall establish written standards for their providers that ensure that provider facilities are accessible to people with disabilities and compliant with all applicable state and federal laws regarding access for people with disabilities.(4) Health care services (excluding emergency health care services) are available at least 40 hours per week, except for weeks including holidays. Such services shall be available until at least 10:00 p.m. at least one day per week or for at least four hours each Saturday, except for Saturdays falling on holidays.(5) Emergency health care services are available and accessible within the service area at all times.(6) Health care services are accessible to covered persons through network providers, or other network arrangement. An adequate network is one in which the care provided to an insured person in a network facility is provided by network providers. The provision of care by an out-of-network provider to an insured person in a network facility renders the network inadequate unless: (A) the insured person, without being prompted to do so, has initiated a request to receive care from that specific out-of-network provider; or(B) coverage is provided on terms no less favorable, and at no greater cost, to the insured person than would have applied had the care been provided by an in-network provider.(7) Network provider services are rendered pursuant to written procedures which include a documented system for monitoring and evaluating accessibility of such care. The monitoring of waiting time for appointments, as described in Sections 2240.15 and 2240.16, shall be a part of such a system.(c) In arranging for network provider services, insurers shall ensure that, for current insured membership and anticipated enrollment growth for the year following the network report: (1) There is the equivalent of at least one full-time physician per 1,200 covered persons and at least the equivalent of one full-time primary care physician per 2,000 covered persons.(2) There are primary care network providers with sufficient capacity to accept covered persons within a maximum travel time of 30 minutes or a maximum travel distance of 15 miles of each covered person's residence or workplace.(3) There are adequate full-time equivalents of primary care and specialist providers in the network accepting new patients covered by the policy to accommodate anticipated enrollment growth.(4) There are medically required network specialists who are certified or eligible for certification by the appropriate specialty board with sufficient capacity to accept covered persons within a maximum travel time of 60 minutes or a maximum travel distance of 30 miles of each covered person's residence or workplace.(5) Notwithstanding the above, the Commissioner may determine that certain medical needs require network specialty care located closer to covered persons when the nature and frequency of use of such health care services, and the standards of Insurance Code 10133.5(b) (3), support such modification.(6) There are mental health and substance use disorder professionals with skills appropriate to care for the mental health and substance use disorder needs of covered persons and with sufficient capacity to accept covered persons within a maximum travel time of 30 minutes or a maximum travel distance of 15 miles of each covered person's residence or workplace. The network must adequately provide for mental health and substance use disorder treatment, including behavioral health therapy. The network must take into account the pattern and frequency with which different therapies, particularly behavioral health therapy, are provided for different patient populations at different ages, such that if it is clinically necessary for a network to have services available in closer proximity to affected covered persons than required by the minimum time and proximity standards stated above then the insurer shall make the services available in such closer proximity. (A) Adequate networks include crisis intervention and stabilization, psychiatric inpatient hospital services, including voluntary psychiatric inpatient services, detoxification, outpatient mental health and substance use evaluation and treatment, psychological testing, outpatient services for monitoring drug therapy, partial hospitalization, intensive outpatient treatment, short-term treatment in a crisis residential program in a licensed psychiatric treatment facility with 24-hour monitoring by clinical staff for stabilization of an acute psychiatric crisis, psychiatric observation for an acute psychiatric crisis and services from mental health providers. Networks must also provide for the diagnosis and medically necessary treatment of severe mental illnesses of a person of any age, and of serious emotional disturbances of a child, including residential care. There must be mental health and substance use disorder providers of sufficient number and type to provide diagnosis and medically necessary treatment through providers acting within their scope of license and scope of competence established by education, training, and experience to diagnose and treat mental health and substance use disorders.
(B) An insurer must establish a reasonable standard approved by the Department for the number and geographic distribution of mental health providers who can treat severe mental illness of a person of any age and serious emotional disturbances of a child, taking into account the various types of mental health practitioners acting within the scope of their licensure, and those practitioners described in subdivision (c) of section 10144.51 of the Insurance Code.(C) The insurer must submit a narrative report describing the adequacy of its mental health and substance use disorder network to the Department for approval no less frequently than annually as part of the network adequacy report required by Section 2240.5.(D) An insurer must include a sufficient number of the appropriate types of mental health and substance use disorder treatment providers and facilities based on normal utilization patterns.(E) An insurer must ensure that covered persons can access information about mental health and substance use disorder services, including benefits, providers, coverage, and other relevant information, by calling a customer service representative, or otherwise contacting the company through an accessible means, during normal business hours.(7) There is a network hospital with sufficient capacity to accept covered persons for covered services within a maximum travel time of 30 minutes or a maximum travel distance of 15 miles of each covered person's residence or workplace. Networks must include hospitals with sufficient capacity to serve the entire population of covered persons based on normal utilization patterns.(8) The network includes adequate numbers of available primary care providers and specialists with admitting and practice privileges at network hospitals.(9) The network includes facilities to provide post-acute care services with sufficient capacity to serve the entire population of covered persons based on normal utilization patterns.(10) The network includes an adequate number of network outpatient retail pharmacies located in sufficient proximity to covered persons to permit adequate routine and emergency access. Similarly, ancillary laboratory and other services dispensed by order or prescription of the prescribing provider are available from contracting providers at locations (where covered persons are personally served) within a reasonable distance from the prescribing provider.(d) Networks shall be designed to optimize access by using a variety of facility types, such as ambulatory surgical centers. Further, access to facilities, such as dialysis centers, shall be designed to accommodate the intensity and frequency of use by the patient population.(e) Networks must provide access to medically appropriate care from a qualified provider. If medically appropriate care cannot be provided within the network, the insurer shall arrange for the required care with available and accessible providers outside the network, with the patient responsible for paying only cost-sharing in an amount equal to the cost-sharing they would have paid for provision of that or a similar service in-network. In addition to in-network copayments and coinsurance, in-network cost sharing includes applicability of the in-network deductible and accrual of cost sharing to the in-network out-of-pocket maximum.(f) An adequate network must also demonstrate the capacity to provide medically necessary organ, tissue, and stem cell transplant surgery. The insurer in its network adequacy report required by Section 2240.5 shall identify and locate each transplant center in its network by name and address, and type of transplant provided in the facility.(g) An adequate network must include a sufficient number of providers to assure access to preventive services required by Insurance Code section 10112.2, including women's preventive care, which includes access to services and contraceptive methods as required by Insurance Code section 10123.196.(h) A service area or network must not be created in a manner designed to discriminate or that results in discrimination against persons because of age, gender, actual or perceived gender identity as defined in Section 2561.1 or on the basis that the insured is a transgender person as defined in Section 2561.1, sexual orientation, disability, national origin, sex, family structure, ethnicity, race, color, ancestry, religion, utilization of medical or mental health or substance use disorder services or supplies, marital status, health insurance coverage, present or predicted disability, expected length of life, degree of medical dependency, quality of life, health status or medical condition, including physical and mental illnesses, claims experience, medical history, genetic information, or evidence of insurability, including conditions arising out of domestic violence.(i) Health carrier standards for the selection and tiering (if the network is a tiered network) of participating providers and facilities shall be developed for primary care professionals and each health care professional specialty and facility, shall include measures related to standards for quality of care and health outcomes, and shall be provided to the Department no less frequently than annually as part of the network adequacy report required by Section 2240.5. The standards shall be used in determining the selection of health care professionals and facilities by the health carrier, its intermediaries and any provider networks with which it contracts. Selection criteria shall not be established in a manner: (1) That would allow a health carrier to avoid high-risk populations by excluding providers because they are located in geographic areas that contain populations or providers presenting a risk of higher than average claims, losses or health services utilization; or(2) That would exclude providers because they treat or specialize in treating populations presenting a risk of higher than average claims, losses or health services utilization.(j) Networks for mountainous rural areas shall take into consideration typical patterns of winter road closures, so as to comply with access and timeliness standards throughout the calendar year.(k) An insurer that uses a tiered network shall meet the standards of this article using the providers available at the lowest cost-sharing tier.(l) The insurer must measure the adequacy of its network at least every six months, and demonstrate and attest to the Department that it has done so, and submit a corrective action plan to the Commissioner if the standards set forth in this article are not met.(m) Notwithstanding the above, the Commissioner may determine that certain medical needs require network providers and/or facilities located closer to covered persons when the nature and frequency of use of such health care services, and the standards of Insurance Code section 10133.5(b) (3), support such modification.(n) Notwithstanding the above, these requirements are not intended to prevent the covered person from selecting providers as allowed by their insurance contract beyond the applicable geographic area specified by these standards.(o) In determining whether an insurer's arrangements for network provider services comply with these regulations, the Commissioner shall consider to the extent the Commissioner deems necessary, the practices of comparable health care service plans licensed under the Knox-Keene Health Care Service Plan Act of 1975 Health and Safety Code Section 1340, et seq.Cal. Code Regs. Tit. 10, § 2240.1
1. Amendment of section heading, section and NOTE 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 106(b), 10133 and 10133.5, Insurance Code.
1. Amendment of section heading, section and Note 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).