In California, state and federal laws impose provider network adequacy standards on all health plans to ensure that plan enrollees can access health care services in a timely manner. While these standards are critical for ensuring that health insurance plans provide meaningful access to necessary care for enrollees, they may put plans at a competitive disadvantage when negotiating contracts with providers such as specialists in short supply. It can be difficult to achieve a balance between cost and access.

Network Adequacy Standards in California: How They Work and Why They Matter examines the existing regulatory framework in California. It reviews standards for network adequacy, availability of waivers for health plans, and the consumer grievance process for patients. California’s requirements are compared to practices in other states and the federal Medicare Advantage program.

The final section of the paper considers new market consolidation forces and discusses the balancing act required within the existing regulatory framework to facilitate affordable health access for all patients in California.

About the Authors

Amy Y. Gu, JD, is the managing editor of The Source on Healthcare Price & Competition, a project of the University of California Hastings College of the Law. Her work focuses on litigation and enforcement actions by state and federal agencies in the provider market. She also conducts research and analysis of state health care legislation for the Database of State Laws Impacting Healthcare Cost and Quality.

Michele Ellson is a JD student at the University of California Hastings College of the Law. Before pursuing a legal career, she worked as a journalist for more than 20 years, earning regional, state, and national honors for her investigative and explanatory reporting.

Katherine L. Gudiksen, PhD, MS, is a senior health policy researcher at The Source on Healthcare Price & Competition. She studies the effects of consolidation and options that state policymakers have to address it, including laws to restrict specific contracting practices, state public option programs, and ways to limit excessive provider rates.

The Source on Healthcare Price & Competition provides up-to-date and easily accessible research and analysis on health care price and competition in the US. For more information, visit sourceonhealthcare.org.