California may rewrite network rules

By BenefitsPro


By Allison Bell

California regulators are considering beefing up health insurance plan provider network regulation.

The California Department of Insurance held a meeting on the topic Tuesday in Sacramento.

Traditionally, health maintenance organizations have put tight restrictions on enrollees' ability to see out-of-network providers.

Preferred provider organization plans have let members see out-of-network doctors but, in many cases, impose higher deductibles, higher co-payment amounts and other rules and payments that encourage members to see in-network providers.

Because the PPO plans had looser restrictions on access to out-of-network doctors and hospitals, many states have had tougher network rules for HMOs, and some have had few or no rules for PPOs.

The Patient Protection and Affordable Care Act requires the plans sold through the new public exchanges to offer adequate networks, but it does not define how many providers of various types a plan network must offer, or how close the providers have to be to the enrollees.

Patient groups and others have complained that exchange plans are not always posting the kinds of provider directories that PPACA requires them to post and that, at this point, the directories that are up seem skimpy.

Dave Jones, the California insurance commissioner, said in a meeting notice about the department's network adequacy regulation that he wants members of the public to give him "written proposals for revising the regulation" and to "start from a clean slate."

Jones is asking for comments about matters such as dental and vision provider standards, behavioral health provider standards, standards for rural areas, and provider availability to new patients.

Anthony Wright, executive director of Health Access California, a California advocacy group, attended the meeting to ask regulators to make sure provider networks can provide the care consumers need when and where they need it.

For low-income and moderate-income consumers, allowing plans to offer small networks that force patients to go out-of-network could expose the enrollees to bills they have no ability to pay, Wright said.

"Going out-of-network can lead to bankruptcy,” Wright said.

Originally published on BenefitsPro.com