MD no longer on list – 156.230 Network Adequacy Standards
(E) His or her health coverage issuer substantially violated a material provision of the health coverage contract.
It’s going to be a stretch, but check page 20 of the specimen platinum policy where you are given the right to choose a network provider and instructions are given on how to do that, BUT the provider lists do NOT work! Provider Status – page 45
(G) He or she was receiving services from a contracting provider under another health benefit plan, as defined in Section 10965 or Section 1399.845 of the Health and Safety Code, for one of the conditions described in subdivision (a) of Section 10133.56 and that provider is no longer participating in the health benefit plan.
Peter Lee — executive director of Covered California — said that state health insurance exchange officials should not have released an online directory of doctors and hospitals last week, the Sacramento Bee‘s “Capitol Alert” reports (Cadelago , “Capitol Alert,” Sacramento Bee, 10/14). CA Healthline
155.420 (4) The qualified individual’s or his or her dependent’s, enrollment or non-enrollment in a QHP is unintentional, inadvertent, or erroneous and is the result of the error, misrepresentation, or inaction of an officer, employee, or agent of the Exchange or HHS, or its instrumentalities as evaluated and determined by the Exchange. In such cases, the Exchange may take such action as may be necessary to correct or eliminate the effects of such error, misrepresentation, or inaction;
(5) The enrollee or, his or her dependent adequately demonstrates to the Exchange that the QHP in which he or she is enrolled substantially violated a material provision of its contract in relation to the enrollee;
On the other hand, Covered CA appears to now what PROOF! Try giving them the Class Action Lawsuit and DOI Investigation?
10133.56. (a) A health insurer that enters into a contract with a professional or institutional provider to provide services at alternative rates of payment pursuant to Section 10133 shall, at the request of an insured, arrange for the completion of covered services by a terminated provider, if the insured is undergoing a course of treatment for any of the following conditions:
(1) An acute condition. An acute condition is a medical condition that involves a sudden onset of symptoms due to an illness, injury, or other medical problem that requires prompt medical attention and that has a limited duration. Completion of covered services shall be provided for the duration of the acute condition.
(2) A serious chronic condition. A serious chronic condition is a medical condition due to a disease, illness, or other medical problem or medical disorder that is serious in nature and that persists without full cure or worsens over an extended period of time or requires ongoing treatment to maintain remission or prevent deterioration. Completion of covered services shall be provided for a period of time necessary to complete a course of treatment and to
arrange for a safe transfer to another provider, as determined by the health insurer in consultation with the insured and the terminated provider and consistent with good professional practice. Completion of covered services under this paragraph shall not exceed 12 months from the contract termination date.
(3) A pregnancy. A pregnancy is the three trimesters of pregnancy and the immediate postpartum period. Completion of covered services shall be provided for the duration of the pregnancy.
(4) A terminal illness. A terminal illness is an incurable or irreversible condition that has a high probability of causing death within one year or less. Completion of covered services shall be provided for the duration of a terminal illness, which may exceed 12 months from the contract termination date.
(5) The care of a newborn child between birth and age 36 months. Completion of covered services under this paragraph shall not exceed 12 months from the contract termination date.
(6) Performance of a surgery or other procedure that has been recommended and documented by the provider to occur within 180 days of the contract’s termination date.
(b) The insurer may require the terminated provider whose services are continued beyond the contract termination date pursuant to this section, to agree in writing to be subject to the same contractual terms and conditions that were imposed upon the provider prior to termination, including, but not limited to, credentialing, hospital privileging, utilization review, peer review, and quality assurance requirements. If the terminated provider does not agree to comply or does not comply with these contractual terms and conditions, the insurer is not required to continue the provider’s services beyond the contract termination date.
(c) Unless otherwise agreed upon between the terminated provider and the insurer or between the terminated provider and the provider group, the agreement shall be construed to require a rate and method of payment to the terminated provider, for the services rendered pursuant to this section, that are the same as the rate and method of payment for the same services while under contract with the insurer and at the time of termination. The provider shall accept the reimbursement as payment in full and shall not bill the insured for any amount in excess of the reimbursement rate, with the exception of
copayments and deductibles pursuant to subdivision (e).
(d) Notice as to the process by which an insured may request completion of covered services pursuant to this section shall be provided in any insurer evidence of coverage and disclosure form issued after March 31, 2004. An insurer shall provide a written copy of this information to its contracting providers and provider groups. An insurer shall also provide a copy to its insureds upon request.
(e) The payment of copayments, deductibles, or other cost-sharing
components by the insured during the period of completion of covered
services with a terminated provider shall be the same copayments,
deductibles, or other cost-sharing components that would be paid by
the insured when receiving care from a provider currently contracting
with the insurer.
(f) If an insurer delegates the responsibility of complying with
this section to its contracting entities, the insurer shall ensure
that the requirements of this section are met.
(g) For the purposes of this section, the following terms have the
(1) “Provider” means a person who is a licentiate as defined in
Section 805 of the Business and Professions Code or a person licensed
under Chapter 2 (commencing with Section 1000) of Division 2 of the
Business and Professions Code.
(2) “Terminated provider” means a provider whose contract to
provide services to insureds is terminated or not renewed by the
insurer or one of the insurer’s contracting provider groups. A
terminated provider is not a provider who voluntarily leaves the
insurer or contracting provider group.
(3) “Provider group” includes a medical group, independent
practice association, or any other similar organization.
(h) This section shall not require an insurer or provider group to
provide for the completion of covered services by a provider whose
contract with the insurer or provider group has been terminated or
not renewed for reasons relating to medical disciplinary cause or
reason, as defined in paragraph (6) of subdivision (a) of Section 805
of the Business and Professions Code, or fraud or other criminal
(i) This section shall not require an insurer to cover services or
provide benefits that are not otherwise covered under the terms and
conditions of the insurer contract.
(j) The provisions contained in this section are in addition to
any other responsibilities of insurers to provide continuity of care
pursuant to this chapter. Nothing in this section shall preclude an
insurer from providing continuity of care beyond the requirements of
(a) General requirement. A QHP issuer must ensure that the provider network of each of its QHPs, as available to all enrollees, meets the following standards—
(1) Includes essential community providers in accordance with §156.235;
(2) Maintains a network that is sufficient in number and types of providers, including providers that specialize in mental health and substance abuse services, to assure that all services will be accessible without unreasonable delay; and,
(3) Is consistent with the network adequacy provisions of section 2702(c) of the PHS Act.
(b) Access to provider directory. A QHP issuer must make its provider directory for a QHP available to the Exchange for publication online in accordance with guidance from the Exchange and to potential enrollees in hard copy upon request. In the provider directory, a QHP issuer must identify providers that are not accepting new patients.
(a) General requirement. (1) A QHP issuer must have a sufficient number and geographic distribution of essential community providers, where available, to ensure reasonable and timely access to a broad range of such providers for low-income, medically underserved individuals in the QHP’s service area, in accordance with the Exchange’s network adequacy standards.
(2) A QHP issuer that provides a majority of covered professional services through physicians employed by the issuer or through a single contracted medical group may instead comply with the alternate standard described in paragraph (b) of this section.
(3) Nothing in this requirement shall be construed to require any QHP to provide coverage for any specific medical procedure provided by the essential community provider.
(b) Alternate standard. A QHP issuer described in paragraph (a)(2) of this section must have a sufficient number and geographic distribution of employed providers and hospital facilities, or providers of its contracted medical group and hospital facilities to ensure reasonable and timely access for low-income, medically underserved individuals in the QHP’s service area, in accordance with the Exchange’s network adequacy standards.
(c) Definition. Essential community providers are providers that serve predominantly low-income, medically underserved individuals, including providers that meet the criteria of paragraph (c)(1) or (2) of this section, and providers that met the criteria under paragraph (c)(1) or (2) of this section on the publication date of this regulation unless the provider lost its status under paragraph (c)(1) or (2) of this section thereafter as a result of violating Federal law:
(1) Health care providers defined in section 340B(a)(4) of the PHS Act; and
(2) Providers described in section 1927(c)(1)(D)(i)(IV) of the Act as set forth by section 221 of Public Law 111-8.
(d) Payment rates. Nothing in paragraph (a) of this section shall be construed to require a QHP issuer to contract with an essential community provider if such provider refuses to accept the generally applicable payment rates of such issuer.
(e) Payment of federally-qualified health centers. If an item or service covered by a QHP is provided by a federally-qualified health center (as defined in section 1905(l)(2)(B) of the Act) to an enrollee of a QHP, the QHP issuer must pay the federally-qualified health center for the item or service an amount that is not less than the amount of payment that would have been paid to the center under section 1902(bb) of the Act for such item or service. Nothing in this paragraph (e) would preclude a QHP issuer and federally-qualified health center from mutually agreeing upon payment rates other than those that would have been paid to the center under section 1902(bb) of the Act, as long as such mutually agreed upon rates are at least equal to the generally applicable payment rates of the issuer indicated in paragraph (d) of this section.
Health Care Reform Insurance Web Portal Requirements RIN 0991-AB63
Medicare Advantage Plans in 2015 will allow you to opt out if the MD Network is significantly changed.
medicare-advantage-plans/#comment-11065carriers have been notifying clients if during the year a provider chooses to cancel their HMO contract since those folks have to pick a new PCP
When Anthem canceled my policy I let them map me over to what they said was the closest coverage to what I had, which was a PPO 20/80.
I never had an issue with finding a doctor or treatment.
I am now paying $150.00 a month more for a plan that is no where near what I had. I was told by one doctors office that I basically had an HMO policy. I can barely find a doctor here in my network. If I go out of network I have a $12,000.deductible and a 50% co pay.
When I went on line
to try to find coverage that I had before it looks like it is double ($800.) what it costs me before and it still isn’t as good. Can this be?
***I’m not at all happy with Health Care Reform. While there is the plus of no more pre-x, I don’t like anything else. I feel that Covered CA (CC) is encouraging the bypassing of agents… just so that no one pays attention to the problems you mention. I doubt CC or the Insurance Companies will tell you about the enrollment periods due to THEIR errors!
All I can say is… shop the quotes in the link below and verify the MD list… provider-finder/
If you want to change, while it isn’t Open Enrollment, it’s my opinion that you can change based on MD change, material violation and error in enrollment. I say opinion as I’m quoting LAW, but I have not seen regulations or court cases defining it.
- Change in Income – Only if already enrolled in Covered CA
- Error – Material Violation by Insurance Company – Covered CA, etc.
- Loss of Current Coverage MEC
- MD not in Network? Right to Special Enrollment?
- Move – New County, State or Back in USA
- Newly Married
- zHistorical – Open Enrollment Information
- zSpecial Enrollment pre-4.2017 * CMS 9929 F * Historical
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