Cal. Code Regs. tit. 10, § 2240.16 – Access Standards for Pediatric Vision and Oral Essential Health Benefits and Specialized Policies that Cover Dental Benefits Only.

(a) Health insurance policies covering the pediatric vision or oral essential health benefit, as defined in subdivision (a)(4) and (a)(5), respectively, of Insurance Code section 10112.27 (regardless of whether such coverage is provided directly through the policy or through subcontracting arrangements), 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), and specialized health insurance policies that cover dental benefits only (as defined in subdivision (c) of Insurance Code section 106) must assure that there are adequate full-time equivalents of network providers accepting new patients covered by the policy to accommodate anticipated enrollment growth.
(b) In addition to ensuring compliance with the clinical appropriateness standard set forth in subdivision (b)(1) of Section 2240.15, each health insurance policy covering the pediatric oral or vision essential health benefit, specialized health insurance policies that provide coverage for the pediatric oral essential health benefit (as defined in in subdivision (a)(5) of Insurance Code section 10112.27), and specialized health insurance policies that cover dental benefits only (as defined in subdivision (c) of Insurance Code section 106) shall ensure that contracted oral and vision provider networks have adequate capacity and availability of licensed health care providers, including generalist and specialist dentists, ophthalmologists, optometrists, and opticians -to offer insureds appointments for covered oral and vision services in accordance with the following requirements:
1. (1) Urgent appointments shall be offered within 72 hours of the time of request for appointment, when consistent with the covered person's individual needs and as required by professionally recognized standards of practice;
2. (2) Non-urgent appointments shall be offered within 36 business days of the request for appointment; and
3. (3) Preventive appointments shall be offered within 40 business days of the request for appointment.
(c) 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 provider's practice 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.

Note: Authority cited: Section 10133.5, Insurance Code. Reference: Sections 106(b), 10133, 10133.5 and 10112.27 Insurance Code.

History

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 heading and 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).