Provider Network Access Standards
California Code of Regulations 10 CCR § 2240 et seq.
- § 2240. Definitions.
- § 2240.1. Adequacy and Accessibility of Provider Services.
- § 2240.15. Network Access Appointment Waiting Time Standards; Quality Assurance; Disclosure and Education.
- § 2240.16. Access Standards for Pediatric Vision and Oral Essential Health Benefits and Specialized Policies that Cover Dental Benefits Only.
- § 2240.2. Insurance Contract Provisions.
- § 2240.3. Provisions of Policies and Certificates.
- § 2240.4. Contracts with Network Providers.
- § 2240.5. Filing and Reporting Requirements.
- § 2240.6. Notice and Information to Covered Persons.
- § 2240.7. Discretionary Waiver of Network Access Standards.
See also – Special Enrollment Periods
Department of Insurance Investigation – errors in lists
“It boggles my mind that insurers can’t keep their list up to date,” “There is no excuse for how messy it is. Health insurers are engaged in false advertising.” Fines coming… CA Health Line 2.10.2017 * Blog Insure Me Kevin.com 2.11.2017 DMHC fined:
- Anthem $250,000; and
- Felser Settlement 5.5.2016
- Blue Shield (BS) $350,000.
State officials said that Blue Shield faced a higher fine because it was less cooperative with regulators. In addition to the fines, DMHC has ordered both insurers to:
- Improve the accuracy of their provider directories; and
- Reimburse enrollees who have been negatively affected by the inaccurate information.
According to the Times, Blue Shield already has reimbursed more than $38 million to consumers who had been charged out-of-network costs. Officials said they do not yet have a reimbursement estimate for Anthem. Learn More CA Health Line 11.4.2015
The emergency regulation requires insurers to:
- Adhere to new standards for appointment wait times (DOI release, 1/5);
- Offer an adequate number of physicians, clinics and hospitals to patients who live in certain areas;
- Provide an accurate list of in-network providers (“KXJZ News,” Capital Public Radio, 1/5);
- Provide out-of-network care options for the same price as in-network care when the number of in-network providers is insufficient; and
- Report to DOI information about their networks and any changes. CA Health Line 1.5.2015
11.18.2014 CA Healthline Errors Found by DMHC – Both Blue Shield and Anthem said the investigation’s methodology was flawed. For example, providers who responded to the survey with “no answer” were recorded as not accepting exchange patients.
So far, complaints have included:
•Failure to receive health plan identification cards and enrollment information; •Inaccurate provider lists; and •Narrow networks.
State regulators mostly are hearing complaints about the difficulty of determining physicians who are included in provider networks. For example, the Humboldt-Del Norte County Medical Society last month analyzed one insurer’s provider lists and found that only about 33% of area physicians were accurately listed (californiahealthline.org)
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Class Action Felser Lawsuit against Blue Cross
- Felser Settlement 5.5.2016
Specifically, the lawsuit alleges that Anthem:
•Delayed giving its customers complete information until it was too late for them to switch their coverage choice;
•Did not inform its customers that it no longer offered out-of-network coverage in four of state’s largest counties — Los Angeles, Orange, San Diego and San Francisco; and
•Misled or did not inform its customers about which doctors and hospitals were participating in the insurer’s new plans. “intentionally misrepresented and concealed the limitations of their plans because it wanted a big market share.”
As a result of those alleged failures, the lawsuit states that many members received thousands of dollars in unexpected medical bills and were unable to see their preferred physician. (californiahealthline.org)
55 page complaint – brief (with my personal ONLY opinions, links and research)If you have a similar problem, Mr. Biedart Esq (Website & Contact Info) would be happy to talk to you. / I happen to know him socially. Here’s a comment from one of our Insurance Clients:
Michael Bidart and his firm represented me in a bad faith claim against my home owners insurer some 13 years ago. As a lawyer myself, I can tell you that they are top notch in the field. Jay Gov. Jerry Brown (D) has signed a bill (SB 964) to increase oversight of insurers’ provider networks, the Sacramento Business Journal reports (Robertson, Sacramento Business Journal, 10/2). bizjournals.com/ Consumer Watchdog – files against CIGNA & Blue Shield californiahealthline.org/ 2nd Lawsuit