Section 2240.5 - Filing and Reporting Requirements(a) For all health insurance policies that include the option of utilizing contracted providers to provide health care services, and specialized health insurance policies, that provide coverage for the pediatric oral essential health benefit (as defined in Insurance Code section 10112.27(a)(5)), the insurer shall file a network adequacy report with the Department, with accompanying documents, as follows:(1) Annually on June 1, a network adequacy report for all health insurance policies providing current coverage or new health insurance policies.(2) Upon request by the Commissioner, a network adequacy report for all health insurance policies providing current coverage or new health insurance policies.(3) Whenever an insurer seeks approval from the department for any policy form that relies upon or includes the option of utilizing contracted network providers to deliver health care services, the insurer shall at the same time file a network adequacy report for the policy form for which approval is sought.(b) Network adequacy reports, and accompanying documents, shall be electronically filed with the Health Policy Approval Bureau through the "California Life & Health" instance of the System for Electronic Rate and Form Filing (SERFF) of the National Association of Insurance Commissioners (NAIC).(c) Network adequacy reports shall consist of:(1) A report describing the number and location of all network providers by county and zip code, including facilities, primary care providers, specialty providers, mental health providers, including behavioral health providers, and substance use disorder providers utilized by the insurer to provide services to covered persons and demonstrating that the insurer is in compliance with all the accessibility and availability requirements of these regulations, and identifying the location and extent of areas of non-compliance.(2) A description of the service area covered by the network, by zip code, and describing any change to the service area since the filing of the most recently filed network adequacy report.(d) The following documents must be submitted with the network adequacy report:(1) An affidavit or attestation acknowledging compliance with all the applicable requirements of this regulation.(2) A copy of the written procedures required by Section 2240.1(b)(7).(3) Complete copies, including all appendices, attachments and exhibits, of the most commonly utilized network provider contracts for each type of provider the insurer (or its agent if using a leased network) includes in the provider network, including but not limited to hospital, individual physician, group physician, laboratory, mental health and substance use disorder providers, rehabilitation and ancillary service contracts. All material changes to provider contracts must be filed with the Health Policy Approval Bureau as they become effective.(4) Copies of all written policies and procedures for recruiting network providers, credentialing or accrediting network providers, contracting with network providers, and managing the insurer's networks, as required by subdivision (a) of Section 2240.4, including the selection and tiering standards (if the network is a tiered network) required by subdivision (g) of Section 2240.1, as well as copies of all written policies and procedures for the coordination of the transition of an insured person from an inpatient hospital to an appropriate community setting consistent with the insured person's post-discharge care needs.(5) The mental health and substance use disorder access report required by subdivision (c)(6)(C) of Section 2240.1.(6) The timely access standards set forth in the insurer's policies and procedures.(7) A report regarding the rate of compliance, during the reporting period, with the time elapsed standards set forth in Sections 2240.15(b) and 2240.16. An insurer may develop data regarding rates of compliance through statistically reliable sampling methodology, including but not limited to provider and insured survey processes.(8) A report regarding any noncompliance by the insurer with the provisions of this article. The report shall state whether or not an incident or pattern described in subdivision (d)(8)(A) or (d)(8)(B) below occurred during the reporting period and, if so, shall include a description of the identified non-compliance and the insurer's responsive investigation, determination and corrective action: (A) Any incidents of noncompliance resulting in substantial harm to an insured, or(B) Any patterns of non-compliance.(9) A description of the implementation and use by the insurer and its contracting providers of triage, telemedicine, and health information technology to provide timely access to care.(10) The results of the most recent annual covered person and provider surveys required by subdivisions (c)(2)(B) and (c)(2)(C), respectively, of Section 2240.15 and a comparison with the results of the prior year's surveys, if any such surveys were conducted, including a discussion of the relative change in survey results.(11) Data regarding the extent to which members used out-of-network services during the reporting period, including the number of out-of-network claims by type of provider, dollar value of total claims, average value per claim, total amount paid by the health plan, average amount paid per claim, total unpaid claim balances and average unpaid claim balance per claim.(12) Data regarding the extent to which members used emergency room services during the reporting period.(13) The information identifying and providing the location of each transplant center in the network by name and address, and type of transplant provided in the facility, required by subdivision (f) of Section 2240.1.(14) A report describing, for each network hospital, the percentage of physicians in each of the specialties of (A) emergency medicine, (B) anesthesiology, (C) radiology, (D) pathology, and (E) neonatology practicing in the hospital who are in the insurer's network(s).(15) Information confirming the status of the insurer's provider network and enrollment at the time of the report, which shall include, on a county-by-county basis, in a format approved by the Department:(A) The insurer's enrollment in each product line; and(B) A complete list of the insurer's contracted physicians, hospitals, and other contracted providers, including name, location, specialty and subspecialty qualifications, California license number and National Provider Identification Number, as applicable. Physician specialty designation shall specify board certification or eligibility consistent with the specialty designations recognized by the American Board of Medical Specialties.(e) The information required by subdivision (d)(15) shall be included with the network adequacy report until the Department implements a web-based application that provides for electronic submission via a web portal designated for the collection of insurer network data. Upon the Department's implementation of the designated network data collection web portal, the information required by subdivision (d)(15) shall be submitted directly to the web portal.(f) An insurer must notify the department immediately at any time that a material change to any of its networks results in the insurer being out of compliance with any of the provisions of these regulations and, at the same time, submit a corrective plan specifying all actions that the insurer is taking, or will take, to come into compliance with these provisions, and estimating the time required to do so.(g) Health insurers that contract for alternative rates of payment with providers shall annually submit a report to the Department through the National Association of Insurance Commissioners (NAIC) System for Electronic Rate and Form Filing (SERFF), no later than March 31, on complaints received in the previous calendar year by the insurer regarding access to care by covered persons and issues with contracted providers. This report shall include the following: (1) A summary of receipt and resolution of complaints from covered persons regarding access to or availability of any of the following services by type of service: primary care services, specialty care services, mental health or substance use disorder professional services and hospital services.(2) A summary of receipt and resolution of complaints received from providers by network and type of service: primary care services, specialty care services, mental health or substance use disorder professional services, hospital services, and other services.(3) The summaries required by subdivisions (g)(1) and (g)(2) above shall include the following:(A) Total number of complaints in the prior calendar year.(B) Description of complainant (as consumer, provider or other).(C) Status of complaint as either resolved or unresolved.(D) Date complaint received.(E) Time from receipt of the complaint to resolution of the complaint, if applicable, or a statement that the complaint is unresolved.(F) Reason or reasons for failure to resolve the complaint, if applicable.(G) Description of complaint resolution, if applicable.(h) The Commissioner may audit compliance with the requirements of this article, and the accuracy of network adequacy reports and supporting documents submitted pursuant to this article, including, without limitation, through requests for additional background information regarding surveys undertaken by an insurer, and through direct surveys of providers and covered persons.(i) The department shall review all network adequacy reports and supporting documents submitted pursuant to this article.(j) The department shall review these complaint reports and any complaints received by the department regarding timely access to care and shall make this information public, consistent with applicable law regarding the confidentiality of personally-identifiable information.(k) The department's review of the reports, documents, and data submitted according to the requirements of this article does not itself act as a waiver of any requirements of this article or of conflicts with California law regarding a given network's design or implementation.Cal. Code Regs. Tit. 10, § 2240.5
1. New section 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 10133 and 10133.5, Insurance Code.
1. New section 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).