Bill Text: CA SB1135 | 2015-2016 | Regular Session | Introduced

NOTE: There are more recent revisions of this legislation. Read Latest Draft

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Bill Title: Health care coverage: notice of timely access to care.

Spectrum: Partisan Bill (Democrat 1-0)

Status: (Passed) 2016-09-23 - Chaptered by Secretary of State. Chapter 500, Statutes of 2016. [SB1135 Detail]

Download: California-2015-SB1135-Introduced.html

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BILL NUMBER: SB 1135	INTRODUCED
	BILL TEXT


INTRODUCED BY   Senator Monning

                        FEBRUARY 18, 2016

   An act to amend Section 1368.02 of, and to add Section 1367.031
to, the Health and Safety Code, and to add Sections 10133.53 and
10133.662 to the Insurance Code, relating to health care coverage.


	LEGISLATIVE COUNSEL'S DIGEST


   SB 1135, as introduced, Monning. Health care coverage: notice of
timely access to care.
   Existing law, the Knox-Keene Health Care Service Plan Act of 1975,
provides for the licensure and regulation of health care service
plans by the Department of Managed Health Care and makes a willful
violation of the act a crime. Existing law also provides for the
regulation of health insurers by the Department of Insurance.
Existing law requires each department to develop and adopt
regulations to ensure that enrollees have access to needed health
care services in a timely manner.
   This bill would require a health care service plan contract or a
health insurance policy that is issued, renewed, or amended on or
after January 1, 2017, and that provides coverage for hospital,
physician, or dental services, to require the plan or insurer to
provide information to enrollees and insureds regarding access to
health care services, including appointment wait times, the
availability of triage or screening services by telephone, the
availability of interpreter services at the time of an appointment,
and information regarding consumer assistance provided by the
licensing agencies, as specified. The bill would also require a
health care service plan or a health insurer to provide a contracting
health care provider with specified information relating to the
provision of referrals or health care services in a timely manner.
   Because a willful violation of the bill's provisions by a health
care service plan would be a crime, the bill would impose a
state-mandated local program.
   The California Constitution requires the state to reimburse local
agencies and school districts for certain costs mandated by the
state. Statutory provisions establish procedures for making that
reimbursement.
   This bill would provide that no reimbursement is required by this
act for a specified reason.
   Vote: majority. Appropriation: no. Fiscal committee: yes.
State-mandated local program: yes.


THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:

  SECTION 1.  Section 1367.031 is added to the Health and Safety
Code, to read:
   1367.031.  (a) A health care service plan contract that is issued,
renewed, or amended on or after January 1, 2017, shall provide that
the health care service plan shall provide information to an enrollee
regarding the standards for timely access to care adopted pursuant
to Section 1367.03 and the information required by this section,
including information related to receipt of interpreter services in a
timely manner, no less than annually.
   (b) A health care service plan that provides or arranges for
hospital or physician services shall at a minimum provide the
following information regarding timely access to care to enrollees
and contracting providers:
   (1) An urgent care appointment shall be offered to the enrollee
within 48 hours of a request for an appointment, unless prior
authorization is required.
   (2) A nonurgent primary care appointment shall be offered to the
enrollee within 10 business days of a request for an appointment.
   (3) A nonurgent appointment with a specialist shall be offered to
the enrollee within 15 business days of a request for an appointment.

   (4) Triage or screening services are available by telephone to the
enrollee 24 hours per day, 7 days per week, from a designated
telephone number. A call made to that number shall be returned by a
qualified health professional within 30 minutes.
   (5) Interpreter services shall be available at the time of the
appointment, if needed.
   (c) A health care service plan that provides coverage for dental
services, either directly or through a contract with another entity,
shall at a minimum provide the following information regarding timely
access to care to enrollees and providers:
   (1) Urgent care shall be offered to an enrollee within 72 hours of
a request for an appointment.
   (2) Nonurgent care shall be offered to an enrollee within 36 days
of a request for an appointment.
   (3) Preventive care shall be offered to an enrollee within 40 days
of a request for an appointment.
   (4) Interpreter services shall be available at the time of the
appointment, if needed.
   (d) The information required to be provided pursuant to this
section shall be provided to an enrollee with individual coverage
upon initial enrollment and annually thereafter upon renewal, and to
enrollees and subscribers with group coverage upon initial enrollment
and annually thereafter upon renewal. The information shall be
provided in the following manner:
   (1) In a separate section of the evidence of coverage titled
"Timely Access to Care."
   (2) In the same manner and place that notice of language
assistance programs is provided pursuant to Section 1367.04 and the
regulations adopted thereunder.
   (3) In a separate section of the provider directory published and
maintained by the health care service plan pursuant to Section
1367.27. The separate section shall be titled "Timely Access to Care."

   (4) On the Internet Web site published and maintained by the
health care service plan, in a manner that allows enrollees and
prospective enrollees to easily locate the information.
   (e) A health care service plan shall also provide the information
required by this section to contracting providers on no less than an
annual basis, and shall additionally provide a contracting provider
with the following information:

   "If one of your patients is unable to obtain a timely referral,
either you or your patient may call the health care service plan or
the Department of Managed Health Care Help Center at 1-888-HMO-2219
to obtain help.
   "California law requires a health care service plan to provide or
arrange for the provision of covered health care services in a timely
manner appropriate for the nature of the enrollee's condition,
consistent with good professional practice. If an appointment is
delayed or extended, the referring or treating health care
professional shall note in the relevant record that a longer waiting
time will not have a detrimental effect on the health of the
enrollee.
   "It is the obligation of the health care service plan to have
sufficient numbers of contracted providers to maintain compliance
with timely access to care for enrollees. If a contracting provider
is unable to provide care in a timely manner consistent with the
requirements for timely access to care, the health care service plan
shall have in place policies and procedures to ensure that the
enrollee shall receive timely access to care."

  SEC. 2.  Section 1368.02 of the Health and Safety Code is amended
to read:
   1368.02.  (a) The director shall establish and maintain a
toll-free telephone number for the purpose of receiving complaints
regarding health care service plans regulated by the director.
   (b)  (1)     Every health care service plan
shall include the department's toll-free telephone number and
Internet Web site address on the card presented by enrollees to
providers as proof of coverage. The department's toll-free telephone
number and Internet Web site address shall be displayed immediately
below the toll-free telephone number for the health care service
plan. The health care service plan may include the following
statement on the card: 

   "Please contact us first regarding any complaint. If you wish to
complain directly to the government agency that licenses this health
plan, please call 1-888-HMO-2219." 

    (2)    Every health care service plan shall
publish the department's toll-free telephone number, the department's
TDD line for the hearing and speech impaired, the plan's telephone
number, and the department's Internet Web site address, on every plan
contract, on every evidence of coverage, on copies of plan grievance
procedures, on plan complaint forms, and on all written notices to
enrollees required under the grievance process of the plan, including
any written communications to an enrollee that offer the enrollee
the opportunity to participate in the grievance process of the plan
and on all written responses to grievances. The department's
telephone number, the department's TDD line, the plan's telephone
number, and the department's Internet Web site address shall be
displayed by the plan in each of these documents in 12-point boldface
type in the following regular type statement:

   "The California Department of Managed Health Care is responsible
for regulating health care service plans. If you have a grievance
against your health plan, you should first telephone your health plan
at (insert health plan's telephone number) and use your health plan'
s grievance process before contacting the department. Utilizing this
grievance procedure does not prohibit any potential legal rights or
remedies that may be available to you. If you need help with a
grievance involving an emergency, a grievance that has not been
satisfactorily resolved by your health plan, or a grievance that has
remained unresolved for more than 30 days, you may call the
department for assistance. You may also be eligible for an
Independent Medical Review (IMR). If you are eligible for IMR, the
IMR process will provide an impartial review of medical decisions
made by a health plan related to the medical necessity of a proposed
service or treatment, coverage decisions for treatments that are
experimental or investigational in nature and payment disputes for
emergency or urgent medical services. The department also has a
toll-free telephone number (1-888-HMO-2219) and a TDD line
(1-877-688-9891) for the hearing and speech impaired. The department'
s Internet Web site http://www.hmohelp.ca.gov has complaint forms,
IMR application forms and instructions online."

  SEC. 3.  Section 10133.53 is added to the Insurance Code, to read:
   10133.53.  (a) A policy of health insurance that is issued,
renewed, or amended on or after January 1, 2017, shall provide that
the insurer shall provide information to an insured regarding the
standards for timely access to care adopted pursuant to Section
10133.5 and the information required by this section, including
information related to receipt of interpreter services in a timely
manner, no less than annually.
   (b) A health insurer for a policy of health insurance, as defined
in subdivision (b) of Section 106, that provides or arranges for
hospital or physician services shall at a minimum provide the
following information regarding timely access to care to insureds and
contracting providers:
   (1) An urgent care appointment shall be offered to the insured
within 48 hours of a request for an appointment, unless prior
authorization is required.
   (2) A nonurgent primary care appointment shall be offered to the
insured within 10 business days of a request for an appointment.
   (3) A nonurgent appointment with a specialist shall be offered to
the insured within 15 business days of a request for an appointment.
   (4) Triage or screening services are available by telephone to the
insured 24 hours per day, 7 days per week, from a designated
telephone number. A call made to that number shall be returned by a
qualified health professional within 30 minutes.
   (5) Interpreter services shall be available at the time of the
appointment, if needed.
   (c) A policy of health insurance that provides coverage for dental
services, either directly or through a contract with another entity,
shall at a minimum provide the following information regarding
timely access to care to insureds and providers:
   (1) Urgent care shall be offered to the insured within 72 hours of
a request for an appointment.
   (2) Nonurgent care shall be offered to the insured within 36 days
of a request for an appointment.
   (3) Preventive care shall be offered to the insured within 40 days
of a request for an appointment.
   (4) Interpreter services shall be available at the time of the
appointment, if needed.
   (d) The information required to be provided pursuant to this
section shall be provided to an insured with individual coverage upon
initial enrollment and annually thereafter upon renewal, and to
insureds and group policy holders with group coverage upon initial
enrollment and annually thereafter upon renewal. The information
shall be provided in the following manner:
   (1) In a separate section of the evidence of coverage titled
"Timely Access to Care."
   (2) In the same manner and place that notice of language
assistance programs is provided pursuant to Section 10133.8 and the
regulations adopted thereunder.
   (3) In a separate section of the provider directory published and
maintained by the insurer pursuant to Section 10133.15. The separate
section shall be titled "Timely Access to Care."
   (4) On the Internet Web site published and maintained by the
insurer, in a manner that allows insureds and prospective insureds to
easily locate the information.
   (e) A health insurer shall also provide the information required
by this section to contracting providers on no less than an annual
basis, and shall additionally provide a contracting provider with the
following information:

   "If one of your patients is unable to obtain a timely referral,
either you or your patient may call the health insurer or the
Department of Insurance at 1-800-927-4357 to obtain help.
   "California law requires a health insurer to provide or arrange
for the provision of covered health care services in a timely manner
appropriate for the nature of the insured's condition, consistent
with good professional practice. If an appointment is delayed or
extended, the referring or treating health care professional shall
note in the relevant record that a longer waiting time will not have
a detrimental effect on the health of the insured.
   "It is the obligation of the health insurer to have sufficient
numbers of contracted providers to maintain compliance with timely
access to care for insureds. If a contracting provider is unable to
provide care in a timely manner consistent with the requirements for
timely access to care, the health insurer shall have in place
policies and procedures to ensure that the insured shall receive
timely access to care."

  SEC. 4.  Section 10133.662 is added to the Insurance Code, to read:

   10133.662.  Every health insurer shall include the department's
toll-free telephone number and Internet Web site address on the card
presented by insureds to providers as proof of coverage. The
department's toll-free telephone number and Internet Web site address
shall be displayed immediately below the toll-free telephone number
for the insurer. The insurer may include the following statement on
the card:

   "Please contact us first regarding any complaint. If you wish to
complain directly to the government agency that licenses this
insurer, please call 1-800-927-4357."
  SEC. 5.  No reimbursement is required by this act pursuant to
Section 6 of Article XIII B of the California Constitution because
the only costs that may be incurred by a local agency or school
district will be incurred because this act creates a new crime or
infraction, eliminates a crime or infraction, or changes the penalty
for a crime or infraction, within the meaning of Section 17556 of the
Government Code, or changes the definition of a crime within the
meaning of Section 6 of Article XIII B of the California
Constitution.