There is positive movement on new state regulations and standards to strengthen oversight of commercial insurance companies and compel them to provide the health care services people need. This comes after years of continuous CHA advocacy with the Department of Managed Health Care, calling attention to the practices of many profit-minded insurance companies that were neglecting the needs of Californians.
The new regulations are expected to be finalized by the end of the year (CHA’s letter recommending several changes to the department’s proposal is here). Broadly, the proposed regulations have the potential to address many hospital concerns and propose several key changes:
- Hospital Capacity and Bed Availability Standards: Establishes rigorous quantitative benchmarks such as an enrollee-to-bed ratio threshold of a maximum of 250 enrollees per licensed acute bed and tracking to measure general acute care hospital sufficiency.
- Post-Acute Care Mandates: Requires health plans to monitor delays and arrange timely post-acute care transfers or home health discharges within strict timeframes (within 48 hours if no prior authorization is needed, or within 96 hours if prior authorization is required).
- Non-Network Referral Thresholds: Implements formal metrics to identify networks with excessive reliance on out-of-network referrals due to access issues for primary care physicians, hospitals, and counseling non-physician mental health professionals.
- Mental Health Utilization & “Ghost” Provider Monitoring: Evaluates clinical encounter data for counseling mental health professionals to ensure networks meet compliance thresholds and penalizes networks harboring inactive or “ghost” providers.
- Required Provider Types & Subcontracted Network Oversight: Updates required provider listings to align with statutory mandates and forces full-service plans to ensure subcontracted plan networks notify them of any impending hospital or provider group contract terminations at least 120 days in advance.
CHA will stay close to state leaders throughout the process as these important regulations as finalized (any regulations must be sure to account for the unique characteristics of integrated health plans so as to not disrupt patient-centered care and coordinated health services) as they could meaningfully improve patient access to care across California.
