1. (a) The definitions set forth in Rule 1300.67.2.2(b), and the documents incorporated therein, are applicable to this section and shall apply to the plan's requirement to meet network adequacy with respect to network adequacy monitoring and all required filings, including those specified in Health and Safety Code sections 1352, 1367.03, 1367.035, 1371.31, 1374.141 and Rules 1300.51, 1300.52, 1300.52.4, and 1300.67.2.1.

2. (b) Within each network service area of a plan, all covered services shall be readily available and accessible to each of the plan's enrollees and shall meet all access requirements and network adequacy standards set forth in the Knox-Keene Act and Title 28, including the requirements set forth in this section:

   1. (1) A plan shall rely only on network providers, as defined in Rule 1300.67.2.2(b), to demonstrate compliance with these standards.
   2. (2) A plan that uses a tiered network shall demonstrate compliance with network adequacy standards and requirements based on providers available at the lowest cost-sharing tier, as defined.
   3. (3) A plan shall ensure it has sufficient numbers of network providers to ensure compliance with this Rule, and with Health and Safety Code section 1367.03 and Rule 1300.67.2.2.

   4. (4) A plan must ensure that sufficient numbers of network providers are readily available to provide health care services to enrollees in the network. Where a provider has not had any clinical encounters with an enrollee in the network during the past calendar year, and the network provider was in the network during that timeframe, it may indicate the provider is not readily available to enrollees in the network for the purposes of network adequacy compliance, absent circumstances that justify a lack of clinical encounters. Such circumstances include situations in which the provider belongs to a highly specialized provider type that is typically minimally utilized, or where the network provider is located in a county that has limited or no network enrollment.

      1. (A) For the purposes of the network adequacy review conducted pursuant to Health and Safety Code sections 1367.03 and 1367.035, and Rule 1300.67.2.2, in addition to the requirements in this Rule, the Department may evaluate plans for sufficient numbers of network providers to provide readily available mental health services. Plans may be considered by the Department to be non-compliant with the sufficiency and availability requirements of this Rule, if the network does not meet the standards and methodology set forth in the document titled Mental Health Utilization Standards and Methodology, which is hereby incorporated by reference. The Department shall use the version of this document noticed on the Department's website at www.dmhc.ca.gov, on or before January 15th of the reporting year, as defined in Rule 1300.67.2.2(b).
      2. (B) The incorporated Mental Health Utilization Standards and Methodology may also be considered by the Department when evaluating network adequacy for the purposes of licensure pursuant to Health and Safety Code sections 1351 and 1352, and Rules 1300.51, 1300.52, and 1300.52.4.
   5. (5) A plan shall rely only on the accurate primary practice address and secondary practice addresses for a network provider, as those terms are defined in Rule 1300.67.2.2(b), to demonstrate compliance with all requirements in this Rule. The Department may require the plan to provide further information to demonstrate compliance with this accuracy requirement when the plan reports multiple secondary practice addresses for a single provider. To determine compliance with this requirement when conducting the network adequacy reviews in subsections (b) through (h) of this Rule, the Department may use the methodology within the “Identifying Provider Location” section of the document titled Geographic Access Measurement Methodology to determine if reported practice addresses appear inaccurate. The Geographic Access Measurement Methodology is hereby incorporated by reference. The Department shall use the version of this document noticed on the Department's website at www.dmhc.ca.gov, on or before January 15th of the reporting year, as defined in Rule 1300.67.2.2(b).
   6. (6) For the purposes of licensure and subsequent filings, pursuant to Health and Safety Code sections 1351 and 1352, where a primary plan network includes providers made available through a subcontracted plan, the primary plan is responsible for ensuring network adequacy for all covered services, including those services delivered through subcontracted plan providers. The Department will determine compliance with network adequacy requirements based on the total set of providers available to all enrollees in the network through the primary plan. Where a subcontracted plan operates a network that is only made available through a plan-to-plan contract, the Department may elect to forego a separate network adequacy evaluation, unless otherwise required by law. Standalone networks will be subject to network adequacy review.

3. (c) Geographic Access Requirements. The location of network providers, as defined in Rule 1300.67.2.2(b), providing the covered services of the plan shall be within reasonable proximity of the business or personal residences of enrollees, and so located as to not result in unreasonable barriers to accessibility. The geographic access standards established in this Rule set forth minimum standards of accessibility that a plan must meet in order to meet network adequacy for a network. A plan must arrange for shorter travel distances or additional provider types within its network, if necessary to ensure that all covered services are readily available and accessible to all enrollees consistent with the standards established in this subsection and subsection (k) below. Where an enrollee is required to travel beyond the standards set forth in this Rule, that service is presumed to be unavailable, as defined in Rule 1300.67.2.2(b).

   1. (1) For the purposes of the network adequacy review conducted pursuant to Health and Safety Code section 1367.035, in addition to the geographic accessibility requirements set forth within subsection (c) of this Rule, the plan shall meet geographic accessibility standards with respect to the location of network specialist physicians, mental health facilities, and non-physician mental health professionals, as established by the Department. A plan that meets the geographic accessibility standards set forth within the incorporated standards and methodology documents identified below shall demonstrate compliance with this provision for the network provider types identified within these documents.

      1. (A) Geographic accessibility standards and the accompanying review methodology for specialist physicians and non-physician mental health professionals shall be set forth in the following documents, which are hereby incorporated by reference:

         1. (i) Geographic Access Standards and Methodology for Specialists, Ancillary, and Facility Providers; and

         2. (ii) Mental Health Geographic Access Standards and Methodology.

            The Department shall use the version of these documents noticed on the Department's website at www.dmhc.ca.gov, on or before January 15th of the reporting year as set forth in Rule 1300.67.2.2(b).

      2. (B) Where a plan is unable to meet the geographic access standards referenced in subsection (A), the Department shall review the plan in accordance with the alternative geographic accessibility standards and methodologies set forth in the Geographic Access Standards and Methodology for Specialists, Ancillary, and Facility Providers, and the Mental Health Geographic Access Standards and Methodology documents, when applicable. The process for requesting alternative accessibility standards set forth in Rule 1300.67.2.1 shall not apply to the geographic accessibility standards for the provider types in these standards and methodology documents, unless otherwise indicated within the incorporated standards and methodology documents.
      3. (C) For network provider types not specified in the Geographic Access Standards and Methodology for Specialists, Ancillary, and Facility Providers, and the Mental Health Geographic Access Standards and Methodology documents, the plan shall ensure the providers are within reasonable proximity of enrollees, and so located as to not result in unreasonable barriers to accessibility.
   2. (2) The geographic accessibility standards set forth in the Geographic Access Standards and Methodology for Specialists, Ancillary, and Facility Providers, and the Mental Health Geographic Access Standards and Methodology may also be considered by the Department when evaluating network adequacy for the purposes of licensure pursuant to Health and Safety Code sections 1351 and 1352, and Rules 1300.51, 1300.52, and 1300.52.4.

   3. (3) Unless otherwise specified in this Rule, with regard to geographic access to primary care providers and hospitals throughout the network service area, the geographic accessibility standards set forth in subsections (i) and (ii) of Item H in subsection (d) of Rule 1300.51 establish the geographic access standards that a plan must meet to demonstrate compliance with the Act for all ZIP Codes in the network service area. These geographic access standards shall apply when evaluating a plan's compliance with the Act in all circumstances where network review is required, including the filings necessitated by Health and Safety Code sections 1351, 1352, 1367.03, 1367.035, 1371.31, 1374.141 and Rules 1300.51, 1300.52, 1300.52.4, and 1300.67.2.1.

      1. (A) These geographic access standards may be superseded for a ZIP Code/County within a network if the Department has approved alternative standards of accessibility under Rule 1300.67.2.1 for the plan's network. The Department may require a plan to file a request to renew or update previously approved alternative standards of accessibility where the facts and circumstances of Rule 1300.6.7.2.1(c) have changed significantly since the original approval of the alternative standard such that a previously approved alternative standard is no longer justified under that Rule. Such circumstances include one or more of the following:

         1. (i) More than three years have passed since the most recent order of approval pertaining to the ZIP Code/County and network;
         2. (ii) Changes to the annual list of ZIP Code/Counties published by the Department impact an approved alternative standard on file with the Department;
         3. (iii) Updates to law or regulation affect the underlying geographic access standards upon which the alternative standards were approved; or
         4. (iv) The Department has information indicating that the approved alternative geographic access standard is no longer justified for a particular ZIP Code, county, or region.

   4. (4) When determining compliance with the geographic access standards for the purposes of network adequacy review set forth in the Knox Keene Act, the Department shall evaluate whether network providers reported to participate in a network are accessible to all current and prospective enrollees throughout the network service area. A plan shall also monitor network accessibility in this manner in accordance with subsection (j) of this Rule.

      1. (A) The Department shall rely upon the methodology set forth in the document titled Geographic Access Measurement Methodology, as incorporated by reference in subsection (b)(5) of this Rule. Where there is a discrepancy in the measurement of driving distance or expected driving time, the Department's measurements made in accordance with the methodology set forth in the Geographic Access Measurement Methodology shall be the accepted measurement of the driving distance and expected driving time afforded by the plan's network.
      2. (B) When, by contract or law, an enrollee may exercise a choice when selecting a provider, the plan may not prevent an enrollee from selecting a network provider, or provider group, even if the network provider or provider group selected is located further from the enrollee than the distance set in the applicable geographic access standards or approved alternative access standards.

   5. (5) The plan shall ensure the network provides geographically accessible services to all population points within the network service area, and all individuals who are enrolled in the network. The plan shall limit enrollment to the network service area, based on the enrollee's residence or workplace.

      1. (A) Where a plan reports significant enrollment in a geographic area outside of the approved network service area, but within this state, the Department may require a plan to file a notice of material modification of the plan's license, consistent with Health and Safety Code section 1352 and supporting regulations, to expand the plan's network service area. Significant enrollment outside of the approved network service area includes:

         1. (i) When at least 1000 enrollees are located in a county outside of the network service area, or within the non-network service area portion of a county that is partially included in the network service area; or
         2. (ii) When more than 10% of the network's enrollment is outside of the network service area, and the network has 5000 or more enrollees.
   6. (6) The geographic access standards set forth in this subsection address network level monitoring and review standards to identify non-compliance with network adequacy. Refer to subsection (k) of this Rule for requirements pertaining to individual enrollee access.
4. (d) Hours of operation and provision for after-hour services shall be reasonable and the network shall include unscheduled urgent services, as defined in Rule 1300.67.2.2(b), within the network service area.
5. (e) Emergency health care services shall be readily available and accessible within the network service area twenty-four hours a day, seven days a week.

6. (f) Network Capacity and Ratios. The ratio of enrollees to staff within a network, including physicians and other health professionals, administrative and other supporting staff, directly or through referrals, shall be such as to reasonably assure that all services offered by the plan will be accessible to enrollees on an appropriate basis without delays detrimental to the health of the enrollees. The ratio standards established in this subsection set forth minimum standards of accessibility that a plan must meet in order to establish network adequacy. A plan must arrange for a greater number of providers or additional provider types within its network, if necessary to reasonably assure that all covered services will be accessible to enrollees on an appropriate basis without delays detrimental to the health of the enrollee.

   1. (1) There shall be at least one full-time equivalent (FTE) physician to each one thousand two hundred (1,200) enrollees and there shall be approximately one full-time equivalent primary care physician for each two thousand (2,000) enrollees, as modified by Health and Safety Code section 1375.9.

   2. (2) For the purposes of the network adequacy review conducted pursuant to Health and Safety Code section 1367.035, in addition to the FTE ratio standards within subsections (f) and (f)(1) of this Rule, the Department shall evaluate the FTE ratio of specified network providers to enrollees according to standards and methodology established by the Department. A plan that meets the FTE ratio standards set forth within the standards and methodology documents incorporated by reference below shall demonstrate compliance with this provision for the network provider types identified within these documents.

      1. (A) Ratio standards and the accompanying review methodology for specialist physicians and non-physician mental health professionals shall be set forth in the following documents, hereby incorporated by reference. The Department shall use the version of these documents noticed on the Department's website at www.dmhc.ca.gov, on or before January 15th of the reporting year set forth in Rule 1300.67.2.2(b):

         1. (i) Primary Care Physician (PCP) Ratio Standards and Methodology;
         2. (ii) Specialist Physician Ratio Standards and Methodology; and
         3. (iii) Counseling Non-Physician Mental Health Professional Ratio Standards and Methodology.
      2. (B) The Department shall review plans in accordance with the alternative standards and methodologies set forth in the Primary Care Physician Ratio Standards and Methodology, the Specialist Physician Ratio Standards and Methodology, and the Counseling Non-Physician Mental Health Professional Ratio Standards and Methodology documents, when applicable. The process for requesting alternative accessibility standards set forth in Rule 1300.67.2.1 shall not apply to ratio standards for specialist physicians and non-physician mental health professionals, unless otherwise indicated within the incorporated standards and methodology documents.
      3. (C) For specialty types not specified in the incorporated Standards and Methodology documents, the plan shall ensure the ratio of enrollees to providers within a network such as to reasonably assure that all services will be accessible to enrollees on an appropriate basis without delays detrimental to the health of the enrollee.
   3. (3) The standards set forth in the Specialist Physician Ratio Standards and Methodology, the Primary Care Physician Ratio Standards and Methodology, and the Counseling Non-Physician Mental Health Professional Ratio Standards and Methodology may also be considered by the Department when evaluating network adequacy for the purposes of licensure pursuant to Health and Safety Code sections 1351 and 1352, and Rules 1300.51, 1300.52, and 1300.52.4.
   4. (4) The ratio standards set forth in this subsection address network level monitoring and review standards to identify non-compliance with network adequacy. Refer to subsection (k) of this Rule for requirements pertaining to individual enrollee access.

7. (g) Required Network Provider Types. A plan's network shall include all network provider types of the appropriate specialty and type necessary to deliver covered services. Within each network, a plan shall provide readily available and accessible physicians, facilities, clinics, mental health providers, and other non-physician medical providers who are appropriately licensed, certified or eligible for certification by the applicable specialty boards, and serve as network providers, as defined in Rule 1300.67.2.2(b).

   1. (1) Each enrollee shall have access to clinically appropriate network providers within the access requirements and network adequacy standards set forth in the Knox-Keene Act and Title 28, including the requirements set forth in this Rule.
   2. (2) For the purposes of the network adequacy review conducted pursuant to Health and Safety Code section 1367.035, a network that does not contain the provider types set forth in the document titled, Required Network Provider Types, which is hereby incorporated by reference, may be considered by the Department to not meet the requirement set forth in this subsection. The Department shall use the version of this document noticed on the Department's website at www.dmhc.ca.gov, on or before January 15^th of the reporting year set forth in Rule 1300.67.2.2(b). Where the required network provider type is not available in the network to an individual enrollee, the service is presumed to be unavailable, as defined in Rule 1300.67.2.2(b).

   3. (3) When a hospital or other facility is a network provider, the plan shall make available individual network providers to deliver all covered services available at the facility, including emergency room care, through the following:

      1. (A) Facility-based providers; and
      2. (B) Providers maintaining medical staff privileges such as hospital admitting privileges, hospital care provision privileges, or emergency medicine privileges, at the facility pursuant to the hospital's credentialing policies and procedures and Rule 1300.51(d)H.
   4. (4) The required network provider type standards set forth in subsection (g)(2) of this Rule address network level monitoring and review standards to identify non-compliance with network adequacy. Refer to subsection (k) of this Rule for requirements pertaining to individual enrollee access.
   5. (5) A plan shall make readily available providers and facilities that deliver services that are appropriate for the nature of the enrollee's condition.

8. (h) Providers Accepting New Patients. Within each network, the plan shall ensure the numbers of network providers who are accepting new patients is sufficient to reasonably assure that all covered services will be accessible to all enrollees on an appropriate basis without delays detrimental to the health of the enrollee and such as to ensure timely access to care for all enrollees.

   1. (1) For the purposes of the network adequacy review conducted pursuant to Health and Safety Code section 1367.035, a plan shall meet standards for network providers that are accepting new patients, as established by the Department, when calculated in accordance with the incorporated standards and methodology documents set forth below.

      1. (A) The standards for the percent of primary care physicians accepting new patients and non-physician mental health professionals accepting new patients shall be set forth in the following documents, which are hereby incorporated by reference. The Department shall use a version of these documents noticed on the Department's website at www.dmhc.ca.gov, on or before January 15th of the reporting year set forth in Rule 1300.67.2.2(b):

         1. (i) Primary Care Physician Accepting New Patients Standards and Methodology; and
         2. (ii) Counseling Non-Physician Mental Health Professional Accepting New Patients Standards and Methodology.
      2. (B) The Department shall review plans in accordance with the alternative standards and methodologies set forth in the Primary Care Physician Accepting New Patients Standards and Methodology and the Counseling Non-Physician Mental Health Professional Accepting New Patients Standards and Methodology documents when applicable. The process for requesting alternative accessibility standards set forth in Rule 1300.67.2.1 shall not apply to the accepting new patients standards, unless otherwise indicated within the standards and methodology document.
   2. (2) The standards set forth in the Primary Care Physician Accepting New Patients Standards and Methodology and the Counseling Non-Physician Mental Health Professional Accepting New Patients Standards and Methodology may also be considered by the Department when evaluating network adequacy for the purposes of licensure pursuant to Health and Safety Code sections 1351 and 1352, and Rules 1300.51, 1300.52, and 1300.52.4.
   3. (3) The required network provider type standards set forth in this subsection address network level monitoring and review standards to identify non-compliance with network adequacy. Refer to subsection (k) of this Rule for requirements pertaining to individual enrollee access.

9. (i) Non-Network Providers. In accordance with Health and Safety Code section 1367.03(a)(7)(C) and Rule 1300.67.2.2(c)(7)(C), a plan shall arrange for the provision of covered services from non-network providers when medically necessary for the enrollee's condition, if the services are unavailable from a network provider. “Unavailable” is defined in Rule 1300.67.2.2(b).

   1. (1) Where a plan is obligated to provide out-of-network services, the plan shall provide and arrange coverage from a non-network provider in a manner that meets the access requirements and network adequacy standards set forth in the Knox-Keene Act and Title 28, including the requirements set forth in this Rule. When arranging out-of-network services the plan shall, at a minimum:

      1. (A) Provide a written notice to enrollees of the plan's out-of-network obligations;
      2. (B) Select and contact out-of-network providers to identify providers who are qualified and available to deliver the services, unless the enrollee has already selected an appropriate provider;
      3. (C) In coordination with the enrollee, schedule the out-of-network appointment within timely access standards in accordance with requirements set forth in Health and Safety Code section 1367.03(a) and (e)(2). This requirement does not prohibit a plan or its delegated provider group from accommodating an enrollee's preference to wait for a later appointment from a specific network provider in accordance with Rule 1300.67.2.2(c)(7)(C);
      4. (D) Provide notification to the enrollee of the out-of-network appointment;
      5. (E) Document the plan's efforts to arrange out-of-network care; and
      6. (F) Limit the enrollee's financial obligations in the agreement between the plan and out-of-network provider in accordance with subsection (k)(2) of this Rule.
   2. (2) A plan shall establish and maintain processes, policies, and procedures to notify enrollees and network providers of the availability of referral to non-network providers. Such notification shall ensure the enrollee is informed that the enrollee's financial obligation to the out-of-network provider(s) is the same as if the services were provided in-network.
   3. (3) The requirements set forth in this subsection apply to networks serving all product types, including products that include an out-of-network benefit.
   4. (4) Delivery of services through a non-network provider does not absolve a plan of its obligation to arrange for those services through a network provider within the access requirements and network adequacy standards in the Knox-Keene Act and Title 28, including the requirements set forth in this Rule.

10. (j) Monitoring Access to Care. Each plan shall have a documented system for monitoring and evaluating access to care, including a system for addressing problems that develop. The monitoring system shall consider the plan's ability to deliver care to enrollees in accordance with the access requirements and network adequacy standards set forth in the Knox-Keene Act and Title 28, including accessibility, availability, continuity of care, network capacity, and timely access requirements.

    1. (1) When identifying network accessibility problems, the plan shall consider enrollee grievances, the unavailability of network providers, shortages of one or more provider types within the network, requests for referrals to non-network providers, delays in access to care, and other indicators of lack of access to covered services for enrollees. The plan shall document any conclusions regarding health plan compliance with these requirements resulting from this review.
    2. (2) For plans that delegate patient care to other health care service plans, provider groups, or other entities, the plan shall have a process for monitoring and evaluating each delegate's ability to deliver care to enrollees in accordance with the access requirements and network adequacy standards set forth in the Knox-Keene Act and Title 28, including accessibility, availability, continuity of care, network capacity, and timely access requirements.

11. (k) Enrollee Right to Access Services. The standards and methodologies set forth in subsections (b) through (h) of this Rule establish the minimum level of compliance necessary for a plan to demonstrate network adequacy, and do not abrogate a plan's duty to arrange for readily available and accessible care to an individual enrollee, appropriate for the nature of the enrollee's condition consistent with good professional practice, and consistent with Health and Safety Code section 1367.03(a)(1). This includes such instances in which the enrollee's circumstances necessitate access to a provider closer than the minimum network standards set forth in this Rule.

    1. (1) The plan shall provide access to providers within reasonable proximity. For the purposes of this subsection, “reasonable proximity” shall be the shorter of the established driving distance standard for the provider grouping referenced in subsection (c)(1)(A) of this Rule, or within 30 miles of the individual enrollee's location when a provider is available within that distance. Driving distances shall be measured in accordance with the Geographic Access Measurement Methodology, as incorporated by reference in subsection (b)(5) of this Rule.
    2. (2) Where a plan must arrange for the provision of covered services from non-network providers for an individual enrollee pursuant to Health and Safety Code section 1367.03(a)(7) and subsection (i) of this Rule, the Plan shall ensure the enrollee has reasonable proximity to providers, as defined within this subsection. The Plan shall ensure the enrollee pays no more than the same cost sharing that the enrollee would pay for the covered services if the services had been delivered by an in-network provider, pursuant to Health and Safety Code section 1367.03(a)(7). A plan's obligation to arrange services from a non-network provider includes making a good faith effort to reach an agreement on payment for services. When determining whether a plan has made a good faith effort, the Department may consider whether the payment rate was arranged in a manner that was at least commensurate with the payment provisions set forth in Health and Safety Code section 1373.96(e)(2).
12. (l) A section of the health education program shall be designated to inform enrollees regarding accessibility of service in accordance with the needs of such enrollees for such information regarding that plan or area.
13. (m) Subject to the requirements of this Rule, a plan shall continue to comply with the standards of accessibility set forth in Item H and Item I of Rule 1300.51.
14. (n) Nothing in this Rule exempts a health plan from complying with federal and state laws regarding mental health and substance use disorder coverage and parity, including, 42 U.S.C. § 300gg-26, 29 CFR § 2590.712, 45 CFR § 146.136, Sections 1374.72 and 1374.76 of the Health and Safety Code, and Rules 1300.74.72, 1300.74.72.01, and 1300.74.721 of this title.

Note: Authority cited: Sections 1343, 1344, 1367.03 and 1367.035, Health and Safety Code. Reference: Sections 1342, 1351, 1352, 1367, 1367.01, 1367.03, 1367.035, 1367.04, 1371.31, 1373.96, 1374.141, 1375.7, 1375.9 and 1386, Health and Safety Code.

1. Amendment of section and new Note filed 3-6-2024; operative 3-6-2024. Submitted to OAL for filing and printing only pursuant to pursuant to Government Code 11343.4(b)(3). Exempt from the APA pursuant to Health and Safety Code section 1367.03, subsections (f)(3) and (f)(5) (Register 2024, No. 10).

2. Amendment filed 4-4-2025; operative 4-4-2025. Submitted to OAL for filing and printing pursuant to Government Code section 11343.8. Exempt from the APA pursuant to Health and Safety Code section 1367.03, subsections (f)(3) and (f)(5) (Register 2025, No. 14).

3. Amendment of section and Note filed 3-18-2026; operative 3-18-2026. Submitted to OAL for filing and printing only pursuant to Government Code section 11343.8. Exempt from the APA pursuant to Health and Safety Code section 1367.03, subsection (f)(5) (Register 2026, No. 12).