Section 2240.7 - Discretionary Waiver of Network Access Standards(a) If an insurer is unable to meet the network access standard(s) required by this article, the insurer may apply to the Commissioner for a discretionary waiver of any network access standards and offer an alternate access delivery system. A waiver application must be resubmitted annually.(b) An application for waiver may only be granted for the following reasons: (1) Absence of practicing providers located within sufficient geographic proximity based upon the time or distance standards of this article.(2) There are sufficient numbers or types of providers or facilities in the service area to meet the standards required by this article, but the insurer demonstrates, through substantial evidence, that, after good faith efforts, it is unable to contract with sufficient providers or facilities to meet the network access standards set forth in this article.(3) An insurer's provider network has been previously approved under this article, and a provider or facility subsequently becomes unavailable within the service area.(4) The application includes a proposal regarding innovative network design, such as primary care medical homes, "Centers of Excellence," or accountable care organizations, but only where the innovative network design is shown to provide a benefit to consumers.(c) In order for a waiver to be granted, the insurer must: (1) Propose an alternate access delivery system that will provide covered persons with access to medically necessary care on a reasonable basis without detriment to their health.(2) Demonstrate that appropriate procedures are in place to ensure that covered persons obtain all covered services in the alternate access delivery system, at no greater cost to the covered persons than if the services were obtained from network providers or facilities. Coinsurance, copayments and deductible requirements shall apply to alternate access delivery systems at the same level they are applied to in-network services.(3) Demonstrate in its alternate access delivery system proposal a reasonable basis for not meeting any standard set forth in this Article, and include an explanation of why the proposed alternative access delivery system provides covered persons with a sufficient number of the appropriate types of providers or facilities to which the standard in question applies.(4) Demonstrate in its alternate access delivery system proposal how the insurer will assist covered persons to locate providers and facilities in a manner that assures both availability and accessibility.(A) Covered persons must be able to obtain health care services from a provider or facility within the closest reasonable proximity of the covered person in a timely manner appropriate for the covered person's health needs.(B) Examples of alternate access delivery systems include, but are not limited to, such insurer strategies as use of out-of-county or out-of-service-area providers or facilities, providing regular scheduled or as-needed transportation from areas within a designated area to those providers or facilities to ensure that such providers or facilities remain reasonably accessible, and exceptions to network standards based upon rural locations in the service area.(d) The application shall include, at a minimum, the following:(1) A description of the affected area and covered persons in that area and how the insurer determined the absence of providers or facilities.(2) Alternatives that were considered, including but not limited to, telemedicine or phone consultation.(3) The applicable reason or reasons set forth in subdivision (b) of this section.(4) Any identified issues or risks that may prevent the alternate access delivery system from providing covered persons with access to medically necessary care on a reasonable basis without detriment to their health.(5) The alternate access delivery system proposal described, and a description of how the proposed alternate access delivery system will satisfy the standards set forth in subdivision (c).(e) The Commissioner shall not approve an alternate access delivery system unless: (1) The insurer provides substantial evidence of good faith efforts on its part to contract with providers or facilities and can demonstrate that there is not an available provider or facility with which the insurer can contract to meet the standards set forth in this article.(2) The proposed alternate access delivery system will provide covered persons with access to medically necessary care on a reasonable basis without detriment to their health.(f) The Department will post on its Internet Web site each waiver or alternative access delivery system that the Department approves under this section on or after June 1, 2016.Cal. Code Regs. Tit. 10, § 2240.7
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). Note: Authority cited: Section 10133.5, Insurance Code. Reference: Sections 10133 and 10133.5, 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).