Section 2240. Definitions

As used in this Article:

(a) “Certificate” means an individual or family certificate of coverage issued pursuant to an insurance contract.

(b) “Covered person” means either a primary covered person or a dependent covered person eligible to receive health care services under the insurance contract providing network provider services.

(c) “Dependent covered person” means someone who is eligible for coverage under an insurance contract through such person’s relationship with or dependency upon a primary covered person.

(d) “Emergency health care services” means health care services rendered for any condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following:

(1) Placing the patient’s health in serious jeopardy,
(2) Serious impairment to bodily functions,
(3) Serious dysfunction of any bodily organ or part,
(4) active labor. “Emergency health care services” also includes services rendered for a psychiatric emergency.
(e) “Essential community provider” (ECP) means providers that serve predominantly low-income, medically underserved individuals, as defined in 45 CFR Section 156.235, published February 27, 2015 at 80 Federal Register 10873-10874, subdivision (c) of which is incorporated herein by this reference. “Essential community provider” also includes:

(1) Disproportionate Share Hospitals as defined at Title 9, California Code of Regulations, section 1706;
(2) Indian Health Care Service Facilities as defined in subdivision (v) of Title 10, California Code of Regulations, section 2699.6500;
(3) Entities licensed as either a community clinic, or a free clinic, under Health and Safety Code section 1204 and entities that are either a community clinic as defined at subdivision (a)(1)(A) of Health and Safety Code section 1204, or a free clinic as defined at subdivision (a)(1)(B) of Health and Safety Code section 1204, that are exempt from licensure under Health and Safety Code section 1206;
(4) Federally Qualified Health Centers as defined at Title 10, California Code of Regulations, section 6410, and
(5) Physician providers whose application for the Medi-Cal Electronic Health Record Incentive Program has been accepted under Welfare and Institutions Code section 14046.2.
(f) “Facility” means an institution providing health care services or a health care setting, including but not limited to hospitals and other licensed inpatient centers, ambulatory surgical or treatment centers, skilled nursing centers, residential treatment centers, urgent care centers, diagnostic, laboratory, and imaging centers, and rehabilitation and other therapeutic health settings.

(g) “Health care professional” means a licensee or certificate holder enumerated in Insurance Code section 10176 or as defined in Insurance Code Section 10133.4 as of the effective date of this Article or as either section may be amended thereafter.

(h) “Insurer” means an insurer who provides “health insurance” as defined in Section 106(b), and includes those who authorize insureds to select providers who have contracted with the insurer for alternative rates of payment as described in Section 10133.

(i) “Limited English proficiency” means a limited ability, or an inability, to speak, read, write, or understand the English language at a level that permits the covered person to interact effectively with the covered person’s health care providers or health insurer.

(j) “Network” means all institutions or health care professionals that are utilized to provide medical services to covered persons pursuant to a contract with an insurer to provide such services at alternative rates as described in Insurance Code Section 10133. A network as defined herein can be directly contracted with by an insurer or leased by an insurer.

(k) “Network provider” means an institution or a health care professional which renders health care services to covered persons pursuant to a contract to provide such services at alternative rates.

(l) “Network provider services” means health care services which are covered under an insurance contract when rendered by a network provider within the service area.

(m) “Non-network provider services” means covered health care services delivered by a health care provider who is not contracted with the insurer either directly or indirectly.

(n) “Primary care physician” means a physician who is responsible for providing initial and primary care to patients, for maintaining the continuity of patient care or for initiating referral for specialist care. A primary care physician may be either a physician whose practice of medicine is limited to general practice or who is a board-certified or board-eligible internist, pediatrician, obstetrician-gynecologist or family practitioner.

(o) “Primary covered person” means a person eligible for coverage under an insurance contract or certificate.

(p) “Service area” means the State of California or any other geographic area within the state designated in the contract within which network provider services are rendered to covered persons for covered benefits.

(q) “Tiered network” or “tiering” means a network of participating providers which has been divided into sub-groupings differentiated by the health insurer according to cost-sharing levels, provider payment, performance ratings, quality scores, or any combination of these or other factors established as a means of influencing the insured person’s choice of provider.

Section 2240.1. Adequacy and Accessibility of Provider Services

(a) The provisions of this article apply to “health insurance” policies as defined by Insurance Code section 106(b). The requirements of this article apply to all health care services covered by the insurance policy. Notwithstanding the above, specialized health insurance policies as defined in Insurance Code section 106(c), other than specialized mental health insurance policies, are exempt from the provisions of this article, except as specified below, in subdivisions (a)(1), (a)(2), and (a)(3) of this Section 2240.1:

(1) Specialized health insurance policies that provide coverage for dental care expenses only shall comply with the following:

(A) Subdivisions (b)(7) and (e) of Section 2240.1,

(B) Subdivisions (b)(1), (b)(3), (b)(4), (b)(6), (b)(11), (b)(12), and (c)(1) of Section 2240.15,

(C) Section 2240.16, and

(D) Section 2240.3;

(2) Specialized health insurance policies that provide coverage for the pediatric oral essential health benefit (as defined in Insurance Code section 10112.27(a)(5)), including but not limited to such policies sold through the California Health Benefit Exchange, shall comply with the following:

(A) Subdivisions (c)(2) and (c)(4) of Section 2240.1,

(B) Subdivisions (c)(2) and (c)(3) of Section 2240.15,

(C) Subdivision (a) of Section 2240.4,

(D) Subdivisions (a), (b), (c), (d)(1), (d)(2), (d)(3), (d)(4), (d)(6), (d)(7), (d)(8), (d)(10), (d)(11), (d)(15), (e), and (f) of Section 2240.5, and

(E) Section 2240.7;

(3) Insurers that issue specialized health insurance policies other than specialized mental health insurance policies shall comply with subdivision (h) of Section 2240.6;

(4) For purposes of this subdivision (a), the term “specialized mental health insurance policies” includes behavioral health-only policies.

(b) In arranging for network provider services, insurers shall ensure that:

(1) Network providers are duly licensed or accredited and that they are sufficient in number, capacity, and specialty to be capable of furnishing the health care services covered by the insurance contract, taking into account the number of covered persons, their characteristics and medical needs including the frequency of accessing needed medical care within the prescribed geographic distances outlined herein and the projected demand for services by type of services. If a network provider does not provide a service otherwise within the provider’s scope of practice covered under the insurance contract, the insurer shall ensure that there are sufficient providers in the network to provide that service. Subdivision (e) of this section shall apply if no providers in the network provide that service.

(2) Decisions pertaining to health care services to be rendered by providers to covered persons are based on such persons’ medical needs and are made by or under the supervision of licensed and appropriate health care professionals.

(3) Facilities used by providers to render health care services are located within reasonable proximity to the work places or the principal residences of the primary covered persons, are reasonably accessible by public transportation and are reasonably accessible, both physically and in terms of provision of service, to covered persons with disabilities. Insurers shall establish written standards for their providers that ensure that provider facilities are accessible to people with disabilities and compliant with all applicable state and federal laws regarding access for people with disabilities.

(4) Health care services (excluding emergency health care services) are available at least 40 hours per week, except for weeks including holidays. Such services shall be available until at least 10:00 p.m. at least one day per week or for at least four hours each Saturday, except for Saturdays falling on holidays.

(5) Emergency health care services are available and accessible within the service area at all times.

(6) Health care services are accessible to covered persons through network providers, or other network arrangement. An adequate network is one in which the care provided to an insured person in a network facility is provided by network providers. The provision of care by an out-of-network provider to an insured person in a network facility renders the network inadequate unless:

(A) the insured person, without being prompted to do so, has initiated a request to receive care from that specific out-of-network provider; or

(B) coverage is provided on terms no less favorable, and at no greater cost, to the insured person than would have applied had the care been provided by an in-network provider.

(7) Network provider services are rendered pursuant to written procedures which include a documented system for monitoring and evaluating accessibility of such care. The monitoring of waiting time for appointments, as described in Sections 2240.15 and 2240.16, shall be a part of such a system.

(c) In arranging for network provider services, insurers shall ensure that, for current insured membership and anticipated enrollment growth for the year following the network report:

(1) There is the equivalent of at least one full-time physician per 1,200 covered persons and at least the equivalent of one full-time primary care physician per 2,000 covered persons.

(2) There are primary care network providers with sufficient capacity to accept covered persons within a maximum travel time of 30 minutes or a maximum travel distance of 15 miles of each covered person’s residence or workplace.

(3) There are adequate full-time equivalents of primary care and specialist providers in the network accepting new patients covered by the policy to accommodate anticipated enrollment growth.

(4) There are medically required network specialists who are certified or eligible for certification by the appropriate specialty board with sufficient capacity to accept covered persons within a maximum travel time of 60 minutes or a maximum travel distance of 30 miles of each covered person’s residence or workplace.

(5) Notwithstanding the above, the Commissioner may determine that certain medical needs require network specialty care located closer to covered persons when the nature and frequency of use of such health care services, and the standards of Insurance Code 10133.5(b) (3), support such modification.

(6) There are mental health and substance use disorder professionals with skills appropriate to care for the mental health and substance use disorder needs of covered persons and with sufficient capacity to accept covered persons within a maximum travel time of 30 minutes or a maximum travel distance of 15 miles of each covered person’s residence or workplace. The network must adequately provide for mental health and substance use disorder treatment, including behavioral health therapy. The network must take into account the pattern and frequency with which different therapies, particularly behavioral health therapy, are provided for different patient populations at different ages, such that if it is clinically necessary for a network to have services available in closer proximity to affected covered persons than required by the minimum time and proximity standards stated above then the insurer shall make the services available in such closer proximity.

(A) Adequate networks include crisis intervention and stabilization, psychiatric inpatient hospital services, including voluntary psychiatric inpatient services, detoxification, outpatient mental health and substance use evaluation and treatment, psychological testing, outpatient services for monitoring drug therapy, partial hospitalization, intensive outpatient treatment, short-term treatment in a crisis residential program in a licensed psychiatric treatment facility with 24-hour monitoring by clinical staff for stabilization of an acute psychiatric crisis, psychiatric observation for an acute psychiatric crisis and services from mental health providers. Networks must also provide for the diagnosis and medically necessary treatment of severe mental illnesses of a person of any age, and of serious emotional disturbances of a child, including residential care.  There must be mental health and substance use disorder providers of sufficient number and type to provide diagnosis and medically necessary treatment through providers acting within their scope of license and scope of competence established by education, training, and experience to diagnose and treat mental health and substance use disorders.

(B) An insurer must establish a reasonable standard approved by the Department for the number and geographic distribution of mental health providers who can treat severe mental illness of a person of any age and serious emotional disturbances of a child, taking into account the various types of mental health practitioners acting within the scope of their licensure, and those practitioners described in subdivision (c) of section 10144.51 of the Insurance Code.

(C) The insurer must submit a narrative report describing the adequacy of its mental health and substance use disorder network to the Department for approval no less frequently than annually as part of the network adequacy report required by Section 2240.5.

(D) An insurer must include a sufficient number of the appropriate types of mental health and substance use disorder treatment providers and facilities based on normal utilization patterns.

(E) An insurer must ensure that covered persons can access information about mental health and substance use disorder services, including benefits, providers, coverage, and other relevant information, by calling a customer service representative, or otherwise contacting the company through an accessible means, during normal business hours.

(7) There is a network hospital with sufficient capacity to accept covered persons for covered services within a maximum travel time of 30 minutes or a maximum travel distance of 15 miles of each covered person’s residence or workplace. Networks must include hospitals with sufficient capacity to serve the entire population of covered persons based on normal utilization patterns.

(8) The network includes adequate numbers of available primary care providers and specialists with admitting and practice privileges at network hospitals.

(9) The network includes facilities to provide post-acute care services with sufficient capacity to serve the entire population of covered persons based on normal utilization patterns.

(10) The network includes an adequate number of network outpatient retail pharmacies located in sufficient proximity to covered persons to permit adequate routine and emergency access. Similarly, ancillary laboratory and other services dispensed by order or prescription of the prescribing provider are available from contracting providers at locations (where covered persons are personally served) within a reasonable distance from the prescribing provider.

(d) Networks shall be designed to optimize access by using a variety of facility types, such as ambulatory surgical centers. Further, access to facilities, such as dialysis centers, shall be designed to accommodate the intensity and frequency of use by the patient population.

(e) Networks must provide access to medically appropriate care from a qualified provider. If medically appropriate care cannot be provided within the network, the insurer shall arrange for the required care with available and accessible providers outside the network, with the patient responsible for paying only cost-sharing in an amount equal to the cost-sharing they would have paid for provision of that or a similar service in-network. In addition to in-network copayments and coinsurance, in-network cost sharing includes applicability of the in-network deductible and accrual of cost sharing to the in-network out-of-pocket maximum.

(f) An adequate network must also demonstrate the capacity to provide medically necessary organ, tissue, and stem cell transplant surgery. The insurer in its network adequacy report required by Section 2240.5 shall identify and locate each transplant center in its network by name and address, and type of transplant provided in the facility.

(g) An adequate network must include a sufficient number of providers to assure access to preventive services required by Insurance Code section 10112.2, including women’s preventive care, which includes access to services and contraceptive methods as required by Insurance Code section 10123.196.

(h) A service area or network must not be created in a manner designed to discriminate or that results in discrimination against persons because of age, gender, actual or perceived gender identity as defined in Section 2561.1 or on the basis that the insured is a transgender person as defined in Section 2561.1, sexual orientation, disability, national origin, sex, family structure, ethnicity, race, color, ancestry, religion, utilization of medical or mental health or substance use disorder services or supplies, marital status, health insurance coverage, present or predicted disability, expected length of life, degree of medical dependency, quality of life, health status or medical condition, including physical and mental illnesses, claims experience, medical history, genetic information, or evidence of insurability, including conditions arising out of domestic violence.

(i) Health carrier standards for the selection and tiering (if the network is a tiered network) of participating providers and facilities shall be developed for primary care professionals and each health care professional specialty and facility, shall include measures related to standards for quality of care and health outcomes, and shall be provided to the Department no less frequently than annually as part of the network adequacy report required by Section 2240.5. The standards shall be used in determining the selection of health care professionals and facilities by the health carrier, its intermediaries and any provider networks with which it contracts. Selection criteria shall not be established in a manner:

(1) That would allow a health carrier to avoid high-risk populations by excluding providers because they are located in geographic areas that contain populations or providers presenting a risk of higher than average claims, losses or health services utilization; or

(2) That would exclude providers because they treat or specialize in treating populations presenting a risk of higher than average claims, losses or health services utilization.

(j) Networks for mountainous rural areas shall take into consideration typical patterns of winter road closures, so as to comply with access and timeliness standards throughout the calendar year.

(k) An insurer that uses a tiered network shall meet the standards of this article using the providers available at the lowest cost-sharing tier.

(l) The insurer must measure the adequacy of its network at least every six months, and demonstrate and attest to the Department that it has done so, and submit a corrective action plan to the Commissioner if the standards set forth in this article are not met.

(m) Notwithstanding the above, the Commissioner may determine that certain medical needs require network providers and/or facilities located closer to covered persons when the nature and frequency of use of such health care services, and the standards of Insurance Code section 10133.5(b) (3), support such modification.

(n) Notwithstanding the above, these requirements are not intended to prevent the covered person from selecting providers as allowed by their insurance contract beyond the applicable geographic area specified by these standards.

(o) In determining whether an insurer’s arrangements for network provider services comply with these regulations, the Commissioner shall consider to the extent the Commissioner deems necessary, the practices of comparable health care service plans licensed under the Knox-Keene Health Care Service Plan Act of 1975 Health and Safety Code Section 1340, et seq.

Section 2240.15. Network Access Appointment Waiting Time Standards; Quality Assurance; Disclosure and Education

(a) For purposes of this section, the following definitions apply:

(1) “Appointment waiting time” means the time from the initial request for health care services by a covered person or the covered person’s treating provider to the earliest date offered for the appointment for services, inclusive of time for obtaining authorization from the insurer or completing any other condition or requirement of the insurer or its contracting providers.

(2) “Preventive care” means health care provided for prevention and early detection of disease, illness, injury or other health condition and, in the case of an insurer includes but is not limited to all of the services required by Insurance Code section 10112.2 (incorporating the requirements of 42 United States Code § 300gg-13 (Public Health Service Act § 2713), and 45 Code of Federal Regulations § 146.130) and subdivision (a)(2)(A)(ii) of section 10112.27 of the Insurance Code.

(3) “Provider group” has the meaning set forth in subdivision (g)(3) of section 10133.56 of the Insurance Code.

(4) “Triage” or “screening” means the assessment of a covered person’s health concerns and symptoms via communication with a physician, registered nurse, or other qualified health professional acting within the physician, registered nurse, or other qualified health professional’s scope of practice and who is trained to screen or triage an insured who may need care, for the purpose of determining the urgency of the covered person’s need for care.

(5) “Triage or screening waiting time” means the time waiting to speak by telephone with a physician, registered nurse, or other qualified health professional acting within the physician, registered nurse, or other qualified health professional’s scope of practice and who is trained to screen or triage an insured who may need care.

(6) “Urgent care” means health care for a condition that requires prompt attention, consistent with subdivision (h)(2) of section 10123.135 of the Insurance Code.

(b) Standards for Timely Access to Care.

(1) Insurers shall provide or arrange for the provision of covered health care services in a timely manner appropriate for the nature of the covered person’s condition consistent with good professional practice. Insurers shall establish and maintain provider networks, policies, procedures and quality assurance monitoring systems and processes sufficient to ensure compliance with this clinical appropriateness standard. An insurer that uses a tiered network must demonstrate compliance with the standards established by this section based on providers available at the lowest cost-sharing tier.

(2) Insurers shall ensure that all network and provider processes necessary to obtain covered health care services, including but not limited to prior authorization processes, are completed in a manner that assures the provision of covered health care services to covered persons in a timely manner appropriate for the covered person’s condition and in compliance with the requirements of this section.

(3) When it is necessary for a provider or a covered person to reschedule an appointment, the appointment shall be promptly rescheduled in a manner that is appropriate for the covered person’s health care needs, and ensures continuity of care consistent with good professional practice, and consistent with the objectives of Section 10133.5 of the Insurance Code and the requirements of this section.

(4) Interpreter services required by Section 10133.8 of the Insurance Code and Article 12 of Title 10 California Code of Regulations, commencing with Section 2538.1, shall be coordinated with scheduled appointments for health care services in a manner that ensures the provision of interpreter services at the time of the appointment consistent with Title 10, California Code of Regulations, section 2538.6 without imposing delay on the scheduling of the appointment. This subdivision (b)(4) does not modify the requirements established in sections 10133.8 or 10133.9 of the Insurance Code.

(5) In addition to ensuring compliance with the clinical appropriateness standard set forth at subdivision (b)(1), each insurer shall ensure that its contracted provider network has adequate capacity and availability of licensed health care providers to offer covered persons appointments that meet the following timeframes:

(A) Urgent care appointments for services that do not require prior authorization: within 48 hours of the request for appointment, except as provided in subdivision (b)(5)(G);

(B) Urgent care appointments for services that require prior authorization: within 96 hours of the request for appointment, except as provided in subdivision (b)(5)(G);

(C) Non-urgent appointments for primary care: within ten business days of the request for appointment, except as provided in subdivisions (b)(5)(G) and (b)

(5)(H);

(D) Non-urgent appointments with specialist physicians: within fifteen business days of the request for appointment, except as provided in subdivisions (b)(5)(G) and (b)(5)(H);

(E) Non-urgent appointments with a non-physician mental health care or substance use disorder provider: within ten business days of the request for appointment, except as provided in subdivisions (b)(5)(G) and (b)(5)(H);

(F) Non-urgent appointments for ancillary services for the diagnosis or treatment of injury, illness, or other health condition: within fifteen business days of the request for appointment, except as provided in subdivisions (b)(5)(G) and (b)(5)(H);

(G) The applicable waiting time for a particular appointment may be extended if the referring or treating licensed health care provider, or the health professional providing triage or screening services, as applicable, acting within the scope of the practice of the licensed health care provider or the health professional providing triage or screen services and consistent with professionally recognized standards of practice, has determined and noted in the relevant record that a longer waiting time will not have a detrimental impact on the health of the covered person;

(H) Preventive care services, as defined at subdivision (a)(2), and periodic follow up care, including but not limited to, standing referrals to specialists for chronic conditions, periodic office visits to monitor and treat pregnancy, cardiac or mental health or substance use disorder conditions, and laboratory and radiological monitoring for recurrence of disease, may be scheduled in advance consistent with professionally recognized standards of practice as determined by the treating licensed health care provider acting within the scope of the treating licensed health care provider’s practice.

(6) Insurers shall ensure they have sufficient numbers of contracted providers to maintain compliance with the standards established by this section. This section does not modify the requirements regarding provider adequacy and accessibility established by this Article.

(7) Insurers shall provide or arrange for the provision, 24 hours per day, 7 days per week, of triage or screening services by telephone as defined in subdivision (a)(5).

(A) Insurers shall ensure that telephone triage or screening services are provided in a timely manner appropriate for the insured’s condition, and that the triage or screening waiting time does not exceed 30 minutes.

(B) An insurer may provide or arrange for the provision of telephone triage or screening services through one or more of the following means: insurer-operated telephone triage or screening services consistent with subdivision (a)(5); telephone medical advice services pursuant to Section 10279 of the Insurance Code; the insurer’s contracted primary care and mental health care or substance use disorder provider network; or other method that provides triage or screening services consistent with the requirements of this subdivision (b)(7)(B).

(8) An insurer that arranges for the provision of telephone triage or screening services through contracted primary care, mental health care, and substance use disorder providers shall require those providers to maintain a procedure for triaging or screening covered persons’ telephone calls, which, at a minimum, shall include the employment, during and after business hours, of a telephone answering machine and/or an answering service and/or office staff, that will inform the caller:

(A) Regarding the length of wait for a return call from the provider; and

(B) How the caller may obtain urgent or emergency care including, when applicable, how to contact another provider who has agreed to be on-call to triage or screen by phone, or if needed, deliver urgent or emergency care.

(9) An insurer that arranges for the provision of triage or screening services through contracted primary care, mental health care, and substance use disorder providers who are unable to meet the time-elapsed standards established in paragraph (b)(7)(A) shall also provide or arrange for the provision of insurer-contracted or operated triage or screening services, which shall, at a minimum, be made available to covered persons affected by that portion of the insurer’s network.

(10) Unlicensed staff persons handling covered person calls may ask questions on behalf of a licensed staff person in order to help ascertain the condition of a covered person so that the covered person can be referred to licensed staff. However, under no circumstances shall unlicensed staff persons use the answers to those questions in an attempt to assess, evaluate, advise, or make any decision regarding the condition of a covered person or determine when a covered person needs to be seen by a licensed medical professional.

(11) Insurers shall ensure that, during normal business hours, the waiting time for a covered person to speak by telephone with an insurer customer service representative knowledgeable and competent regarding the covered person’s questions and concerns shall not exceed ten (10) minutes, or that the covered person will receive a scheduled call-back within 30 minutes.

(12) For health insurance policies providing coverage for the pediatric oral and vision essential health benefit, and specialized health insurance policies that provide coverage for dental care expenses only, insurers shall require that contracted providers employ an answering service or a telephone answering machine during non-business hours which provides instructions regarding how covered persons may obtain urgent or emergency care including, when applicable, how to contact another provider who has agreed to be on-call to triage or screen by phone or, if needed, deliver urgent or emergency care.

(c) Quality Assurance Processes. Each insurer shall have written quality assurance systems, policies and procedures designed to ensure that the insurer’s provider network is sufficient to provide accessibility, availability and continuity of covered health care services as required by the Insurance Code and this section. An insurer’s quality assurance program shall address:

(1) Standards for the provision of covered services in a timely manner consistent with the requirements of this section and Section 2240.16.

(2) Compliance monitoring policies and procedures, filed for the Commissioner’s review and approval, designed to accurately measure the accessibility and availability of contracted providers, which shall include:

(A) Tracking and documenting network capacity and availability with respect to the standards set forth in, subdivision (b) of this Section 2240.15, and Section 2240.16; and

(B) Conducting an annual covered person experience survey, which shall be conducted in accordance with valid and reliable survey methodology and designed to ascertain compliance with the standards set forth in subdivision (b) of this section; however, for health insurance policies that provide coverage for the pediatric vision or oral essential health benefit and for specialized health insurance policies that provide coverage for the pediatric oral essential health benefit (as defined in subdivision (a)(5) of Insurance Code section 10112.27), the survey shall be designed to ascertain compliance with the standards set forth in Section 2240.16. The Department will make the aggregated results of this survey publicly available; and

(C) Conducting an annual provider survey, which shall be conducted in accordance with valid and reliable survey methodology and designed to solicit, from physicians and non-physician mental health and substance use disorder providers, perspectives and concerns regarding compliance with the standards set forth at subdivision (b) of this section; however, for health insurance policies that provide coverage for the pediatric vision or oral essential health benefit, and for specialized health insurance policies that provide coverage for the pediatric oral essential health benefit (as defined in subdivision (a)(5) of Insurance Code section 10112.27), the survey shall be designed to solicit perspectives and concerns from providers regarding compliance with the standards set forth in Section 2240.16. The Department will make the results of this survey publicly available; and

(D) Reviewing and evaluating, no less frequently than quarterly, the information available to the insurer regarding accessibility, availability and continuity of care, including but not limited to information obtained through covered person and provider surveys, covered person grievances and appeals, and triage or screening services.

(3) An insurer shall implement prompt investigation and corrective action when compliance monitoring discloses that the insurer’s provider network is not sufficient to ensure timely access as required by this section, including but not limited to taking all necessary and appropriate action to identify the cause(s) underlying identified timely access deficiencies and to bring its network into compliance. Insurers shall give advance written notice to all contracted providers affected by a corrective action, and shall include: a description of the identified deficiencies, the rationale for the corrective action, and the name and telephone number of the person authorized to respond to provider concerns regarding the insurer’s corrective action.

(d) Disclosure and Education.

(1) Insurers shall disclose in all policies, certificates, and coverage materials the availability of triage or screening services and how to obtain those services. Insurers shall disclose annually, in insurer newsletters or comparable communications to covered persons, the Department’s standards for timely access, the insurer’s process for ensuring timely access, and what steps a covered person should take when experiencing access problems inconsistent with timely access standards, including when and how to access applicable Department and insurer helplines.

(2) The telephone number at which covered persons can access triage and screening services shall be included on covered person membership cards. An insurer may comply with this requirement through an additional selection in its automated customer service telephone answering system, where applicable, provided that the customer service number is included on the covered person’s membership card.