SBCMS News/Media

Legislature passes bill that would require annual reports from insurers on provider network adequacy

The legislature has passed a bill that would require Medi-Cal managed plans and insurers offering individual plans through Covered California to provide annual reports to the California Department of Managed Health Care (DMHC) about the adequacy of their provider networks. The bill also requires DMHC to post annual reviews regarding plan compliance on its website. 

This California Medical Association (CMA) supported the bill, SB 964 (Hernandez), which passed late last week and is now on the governor's desk awaiting his signature. 

With roughly 1.4 million Californians newly enrolled in Covered California products since October of last year, the importance of adequate provider networks has been paramount. The new insurance products with narrowed networks, however, have made it  exceedingly difficult for both physicians and patients to find out who is in and out of these networks.

Network adequacy is key to implementing the Affordable Care Act (ACA) in the state and fulfilling the promise of health care coverage for all California citizens — yet coverage means little without access to in-network providers. Two surveys conducted by the California physician community suggest that Californians may still have difficulties with the access component of this health care promise.

First, a CMA survey conducted this spring, which resulted in an unprecedented response from over 2,300 physicians in less than two days, found that more than half of respondents have experienced difficulty finding an in-network physician or facility to which they can refer their Covered California patients.

Second, a Humboldt-Del Norte County Medical Society survey (link to survey) found that two-thirds of the listings in Anthem Blue Cross’s family practice physician directory in Humboldt County are inaccurate and that roughly three-quarters of the directory listings would not connect a consumer to a physician accepting new Covered California patients.

There have also been several lawsuits filed by consumers against insurers for deceptive provider directories, and the state legislature has requested an audit of the Department of Health Care Services’ Medi-Cal provider directories for inaccuracies.

As these surveys and lawsuits suggest, network adequacy standards do not protect patients unless compliance is being sufficiently monitored and enforcement is enough to ensure access to care. While this bill is another positive step towards ensuring patients have adequate networks and accurate provider directories, CMA also believes that it is critically important that the state gives regulators the resources they need to enforce the network standards that are already on the books.

CMA hopes to continue working with state partners and fellow stakeholders to ensure that Californians will have coverage that translates to access going forward.

Covered CA Materials for Your Patients

The CMA Foundation (CMAF) and California Medical Association (CMA) have been awarded a grant from Covered California, the state's new health benefit exchange/marketplace.  The purpose of the grant is to educate doctors and their health care team about Covered California and resources that are available for patients on where to go for additional information on programs that may be available based on their specific needs. 

The CMA Foundation, in partnership with San Bernardino County Medical Society, can provide you with patient education materials to distribute to patients asking for advice and assistance with Covered California. If you are interested in receiving resources for your office, please complete the request form and return to the CMA Foundation.

Health Benefit Exchange Toolkit Now Available

In 2010, Congress passed historic sweeping health care legislation, the Patient Protection and Affordable Care Act (ACA), which reformed the for-profit health insurance industry and beginning in 2014 will provide health insurance to most of the nation’s uninsured. Under the ACA, two thirds of California’s uninsured will be covered by private insurance through a health insurance exchange purchasing pool. The exchange’s goal is to start pre-enrollment in October 2013.

CMA has developed a new toolkit titled, CMA’s Got You Covered: A physician’s guide to Covered California, the state’s health benefit exchange, to educate physicians on the exchange and ensure that they are aware of important issues related to exchange plan contracting.

The toolkit is available free to SBCMS/CMA members only at www.cmanet.org/exchange.