California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 7 - Standards › Section 1300.67.2.1 - Geographic Accessibility Standards

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Subject to subsections (a) and (b) of this section, a plan
					 may rely, for the purposes of satisfying the requirements for geographic
					 accessibility, on the standards of accessibility set forth in Item H of Section
					 1300.51 and in Section
					 1300.67.2.
(a) If, given the facts and circumstances
				  with regard to any portion of its service area, a plan's standards of
				  accessibility adopted pursuant to Item H of Section
				  1300.51 and/or Section
				  1300.67.2 are unreasonably
				  restrictive, or the service area is within a county with a population of
				  500,000 or fewer, and is within a county that, as of January 1, 2002, has two
				  or fewer full service health care service plans in the commercial market, the
				  plan may propose alternative standards of accessibility for that portion of its
				  service area. The plan shall do so by including such alternative standards in
				  writing in its plan license application or in a notice of material
				  modification. The plan shall also include a description of the reasons
				  justifying the less restrictive standards based on those facts and
				  circumstances. If the Department rejects the plan's proposal, the Department
				  shall inform the plan of the Department's reason for doing so.
(b) If, in its review of a plan license
				  application or a notice of material modification, the Department believes the
				  accessibility standards set forth in Item H of Section
				  1300.51 and/or Section
				  1300.67.2 are insufficiently
				  prescribed or articulated or are inappropriate given the facts and
				  circumstances with regard to a portion of a plan's service area, the Department
				  shall inform the plan that the Department will not allow application of those
				  standards to that portion of the plan's service area. The Department shall also
				  inform the plan of the Department's reasons for rejecting the application of
				  those standards.
(c) The facts and
				  circumstances to be included in a discussion of the reasons justifying the
				  standards of accessibility proposed by the plan pursuant to subsection (a) or
				  (b) of this section shall include, to the extent relevant, but shall not
				  necessarily be limited to the following:
(1)
				  whether the plan contract involved is a group health care service plan contract
				  or an individual health care service plan contract;
(2) whether the plan contract is a
				  full-service health care service plan contract or a specialized health care
				  service plan contract, and if the latter, whether emergency services need not
				  be covered;
(3) the uniqueness of
				  the services to be offered;
(4)
				  whether the portion of the service area involved is urban or rural;
(5) population density in the portion of the
				  service area, including whether the service area is within a county with a
				  population of 500,000 or fewer;
(6)
				  whether, as of January 1, 2002, the county containing the service area had two
				  or fewer full service health care service plans providing coverage to the
				  entire county in the commercial market;
(7) the distribution of enrollees in the
				  portion of the service area;
(8)
				  the availability and distribution of primary care physicians;
(9) the availability and distribution of
				  other types of providers;
(10) the
				  existence of exclusive contracts in the provider community or other barriers to
				  entry;
(11) patterns of practice in
				  the portion of the service area;
(12) driving times;
(13) waiting times for
				  appointments;
(14) whether the plan
				  or any other health care service plan currently has significant operations in
				  that portion of the service area; and
(15) other standards of accessibility that
				  the Director deems necessary or appropriate in the public interest and
				  consistent with the intent and purpose of the Act as applied to specific facts
				  or circumstances.