Section 2240.15 - Network Access Appointment Waiting Time Standards; Quality Assurance; Disclosure and Education(a) For purposes of this section, the following definitions apply: (1) "Appointment waiting time" means the time from the initial request for health care services by a covered person or the covered person's treating provider to the earliest date offered for the appointment for services, inclusive of time for obtaining authorization from the insurer or completing any other condition or requirement of the insurer or its contracting providers.(2) "Preventive care" means health care provided for prevention and early detection of disease, illness, injury or other health condition and, in the case of an insurer includes but is not limited to all of the services required by Insurance Code section 10112.2 (incorporating the requirements of 42 United States Code § 300gg-13 (Public Health Service Act § 2713), and 45 Code of Federal Regulations § 146.130) and subdivision (a)(2)(A)(ii) of section 10112.27 of the Insurance Code.(3) "Provider group" has the meaning set forth in subdivision (g)(3) of section 10133.56 of the Insurance Code.(4) "Triage" or "screening" means the assessment of a covered person's health concerns and symptoms via communication with a physician, registered nurse, or other qualified health professional acting within the physician, registered nurse, or other qualified health professional's scope of practice and who is trained to screen or triage an insured who may need care, for the purpose of determining the urgency of the covered person's need for care.(5) "Triage or screening waiting time" means the time waiting to speak by telephone with a physician, registered nurse, or other qualified health professional acting within the physician, registered nurse, or other qualified health professional's scope of practice and who is trained to screen or triage an insured who may need care.(6) "Urgent care" means health care for a condition that requires prompt attention, consistent with subdivision (h)(2) of section 10123.135 of the Insurance Code.(b) Standards for Timely Access to Care. (1) Insurers shall provide or arrange for the provision of covered health care services in a timely manner appropriate for the nature of the covered person's condition consistent with good professional practice. Insurers shall establish and maintain provider networks, policies, procedures and quality assurance monitoring systems and processes sufficient to ensure compliance with this clinical appropriateness standard. An insurer that uses a tiered network must demonstrate compliance with the standards established by this section based on providers available at the lowest cost-sharing tier.(2) Insurers shall ensure that all network and provider processes necessary to obtain covered health care services, including but not limited to prior authorization processes, are completed in a manner that assures the provision of covered health care services to covered persons in a timely manner appropriate for the covered person's condition and in compliance with the requirements of this section.(3) When it is necessary for a provider or a covered person to reschedule an appointment, the appointment shall be promptly rescheduled in a manner that is appropriate for the covered person's health care needs, and ensures continuity of care consistent with good professional practice, and consistent with the objectives of Section 10133.5 of the Insurance Code and the requirements of this section.(4) Interpreter services required by Section 10133.8 of the Insurance Code and Article 12 of Title 10 California Code of Regulations, commencing with Section 2538.1, shall be coordinated with scheduled appointments for health care services in a manner that ensures the provision of interpreter services at the time of the appointment consistent with Title 10, California Code of Regulations, section 2538.6 without imposing delay on the scheduling of the appointment. This subdivision (b)(4) does not modify the requirements established in sections 10133.8 or 10133.9 of the Insurance Code.(5) In addition to ensuring compliance with the clinical appropriateness standard set forth at subdivision (b)(1), each insurer shall ensure that its contracted provider network has adequate capacity and availability of licensed health care providers to offer covered persons appointments that meet the following timeframes: (A) Urgent care appointments for services that do not require prior authorization: within 48 hours of the request for appointment, except as provided in subdivision (b)(5)(G);(B) Urgent care appointments for services that require prior authorization: within 96 hours of the request for appointment, except as provided in subdivision (b)(5)(G);(C) Non-urgent appointments for primary care: within ten business days of the request for appointment, except as provided in subdivisions (b)(5)(G) and (b)(5)(H);(D) Non-urgent appointments with specialist physicians: within fifteen business days of the request for appointment, except as provided in subdivisions (b)(5)(G) and (b)(5)(H);(E) Non-urgent appointments with a non-physician mental health care or substance use disorder provider: within ten business days of the request for appointment, except as provided in subdivisions (b)(5)(G) and (b)(5)(H);(F) Non-urgent appointments for ancillary services for the diagnosis or treatment of injury, illness, or other health condition: within fifteen business days of the request for appointment, except as provided in subdivisions (b)(5)(G) and (b)(5)(H);(G) The applicable waiting time for a particular appointment may be extended if the referring or treating licensed health care provider, or the health professional providing triage or screening services, as applicable, acting within the scope of the practice of the licensed health care provider or the health professional providing triage or screen services and consistent with professionally recognized standards of practice, has determined and noted in the relevant record that a longer waiting time will not have a detrimental impact on the health of the covered person;(H) Preventive care services, as defined at subdivision (a)(2), and periodic follow up care, including but not limited to, standing referrals to specialists for chronic conditions, periodic office visits to monitor and treat pregnancy, cardiac or mental health or substance use disorder conditions, and laboratory and radiological monitoring for recurrence of disease, may be scheduled in advance consistent with professionally recognized standards of practice as determined by the treating licensed health care provider acting within the scope of the treating licensed health care provider's practice.(6) Insurers shall ensure they have sufficient numbers of contracted providers to maintain compliance with the standards established by this section. This section does not modify the requirements regarding provider adequacy and accessibility established by this Article.(7) Insurers shall provide or arrange for the provision, 24 hours per day, 7 days per week, of triage or screening services by telephone as defined in subdivision (a)(5). (A) Insurers shall ensure that telephone triage or screening services are provided in a timely manner appropriate for the insured's condition, and that the triage or screening waiting time does not exceed 30 minutes.(B) An insurer may provide or arrange for the provision of telephone triage or screening services through one or more of the following means: insurer-operated telephone triage or screening services consistent with subdivision (a)(5); telephone medical advice services pursuant to Section 10279 of the Insurance Code; the insurer's contracted primary care and mental health care or substance use disorder provider network; or other method that provides triage or screening services consistent with the requirements of this subdivision (b)(7)(B).(8) An insurer that arranges for the provision of telephone triage or screening services through contracted primary care, mental health care, and substance use disorder providers shall require those providers to maintain a procedure for triaging or screening covered persons' telephone calls, which, at a minimum, shall include the employment, during and after business hours, of a telephone answering machine and/or an answering service and/or office staff, that will inform the caller: (A) Regarding the length of wait for a return call from the provider; and(B) How the caller may obtain urgent or emergency care including, when applicable, how to contact another provider who has agreed to be on-call to triage or screen by phone, or if needed, deliver urgent or emergency care.(9) An insurer that arranges for the provision of triage or screening services through contracted primary care, mental health care, and substance use disorder providers who are unable to meet the time-elapsed standards established in paragraph (b)(7)(A) shall also provide or arrange for the provision of insurer-contracted or operated triage or screening services, which shall, at a minimum, be made available to covered persons affected by that portion of the insurer's network.(10) Unlicensed staff persons handling covered person calls may ask questions on behalf of a licensed staff person in order to help ascertain the condition of a covered person so that the covered person can be referred to licensed staff. However, under no circumstances shall unlicensed staff persons use the answers to those questions in an attempt to assess, evaluate, advise, or make any decision regarding the condition of a covered person or determine when a covered person needs to be seen by a licensed medical professional.(11) Insurers shall ensure that, during normal business hours, the waiting time for a covered person to speak by telephone with an insurer customer service representative knowledgeable and competent regarding the covered person's questions and concerns shall not exceed ten (10) minutes, or that the covered person will receive a scheduled call-back within 30 minutes.(12) For health insurance policies providing coverage for the pediatric oral and vision essential health benefit, and specialized health insurance policies that provide coverage for dental care expenses only, insurers shall require that contracted providers employ an answering service or a telephone answering machine during non-business hours which provides instructions regarding how covered persons may obtain urgent or emergency care including, when applicable, how to contact another provider who has agreed to be on-call to triage or screen by phone or, if needed, deliver urgent or emergency care.(c) Quality Assurance Processes. Each insurer shall have written quality assurance systems, policies and procedures designed to ensure that the insurer's provider network is sufficient to provide accessibility, availability and continuity of covered health care services as required by the Insurance Code and this section. An insurer's quality assurance program shall address:(1) Standards for the provision of covered services in a timely manner consistent with the requirements of this section and Section 2240.16.(2) Compliance monitoring policies and procedures, filed for the Commissioner's review and approval, designed to accurately measure the accessibility and availability of contracted providers, which shall include: (A) Tracking and documenting network capacity and availability with respect to the standards set forth in, subdivision (b) of this Section 2240.15, and Section 2240.16; and(B) Conducting an annual covered person experience survey, which shall be conducted in accordance with valid and reliable survey methodology and designed to ascertain compliance with the standards set forth in subdivision (b) of this section; however, for health insurance policies that provide coverage for the pediatric vision or oral essential health benefit and for specialized health insurance policies that provide coverage for the pediatric oral essential health benefit (as defined in subdivision (a)(5) of Insurance Code section 10112.27), the survey shall be designed to ascertain compliance with the standards set forth in Section 2240.16. The Department will make the aggregated results of this survey publicly available; and(C) Conducting an annual provider survey, which shall be conducted in accordance with valid and reliable survey methodology and designed to solicit, from physicians and non-physician mental health and substance use disorder providers, perspectives and concerns regarding compliance with the standards set forth at subdivision (b) of this section; however, for health insurance policies that provide coverage for the pediatric vision or oral essential health benefit, and for specialized health insurance policies that provide coverage for the pediatric oral essential health benefit (as defined in subdivision (a)(5) of Insurance Code section 10112.27), the survey shall be designed to solicit perspectives and concerns from providers regarding compliance with the standards set forth in Section 2240.16. The Department will make the results of this survey publicly available; and(D) Reviewing and evaluating, no less frequently than quarterly, the information available to the insurer regarding accessibility, availability and continuity of care, including but not limited to information obtained through covered person and provider surveys, covered person grievances and appeals, and triage or screening services.(3) An insurer shall implement prompt investigation and corrective action when compliance monitoring discloses that the insurer's provider network is not sufficient to ensure timely access as required by this section, including but not limited to taking all necessary and appropriate action to identify the cause(s) underlying identified timely access deficiencies and to bring its network into compliance. Insurers shall give advance written notice to all contracted providers affected by a corrective action, and shall include: a description of the identified deficiencies, the rationale for the corrective action, and the name and telephone number of the person authorized to respond to provider concerns regarding the insurer's corrective action.(d) Disclosure and Education. (1) Insurers shall disclose in all policies, certificates, and coverage materials the availability of triage or screening services and how to obtain those services. Insurers shall disclose annually, in insurer newsletters or comparable communications to covered persons, the Department's standards for timely access, the insurer's process for ensuring timely access, and what steps a covered person should take when experiencing access problems inconsistent with timely access standards, including when and how to access applicable Department and insurer helplines.(2) The telephone number at which covered persons can access triage and screening services shall be included on covered person membership cards. An insurer may comply with this requirement through an additional selection in its automated customer service telephone answering system, where applicable, provided that the customer service number is included on the covered person's membership card.Cal. Code Regs. Tit. 10, § 2240.15
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).
5. Change without regulatory effect amending subsections (a)(4)-(5) and (b)(5)(G)-(H) filed 7-14-2021 pursuant to section 100, title 1, California Code of Regulations (Register 2021, No. 29). Filing deadline specified in Government Code section 11349.3(a) extended 60 calendar days pursuant to Executive Order N-40-20. Note: Authority cited: Section 10133.5, Insurance Code. Reference: Sections 106(b), 10133, 10133.5 and 10133.8, Insurance Code.
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).
5. Change without regulatory effect amending subsections (a)(4)-(5) and (b)(5)(G)-(H) filed 7-14-2021 pursuant to section 100, title 1, California Code of Regulations (Register 2021, No. 29). Filing deadline specified in Government Code section 11349.3(a) extended 60 calendar days pursuant to Executive Order N-40-20.