Bill Text: CA SB137 | 2015-2016 | Regular Session | Amended
NOTE: There are more recent revisions of this legislation. Read Latest Draft
Bill Title: Health care coverage: provider directories.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Passed) 2015-10-08 - Chaptered by Secretary of State. Chapter 649, Statutes of 2015. [SB137 Detail]
Download: California-2015-SB137-Amended.html
Bill Title: Health care coverage: provider directories.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Passed) 2015-10-08 - Chaptered by Secretary of State. Chapter 649, Statutes of 2015. [SB137 Detail]
Download: California-2015-SB137-Amended.html
BILL NUMBER: SB 137 AMENDED
BILL TEXT
AMENDED IN ASSEMBLY JULY 16, 2015
AMENDED IN ASSEMBLY JULY 2, 2015
AMENDED IN SENATE JUNE 1, 2015
AMENDED IN SENATE APRIL 21, 2015
AMENDED IN SENATE MARCH 26, 2015
INTRODUCED BY Senator Hernandez
JANUARY 26, 2015
An act to add Sections Section
1367.27 and 1367.28 to to, and repeal Section
1367.26 of, the Health and Safety Code, and to add
Sections Section 10133.15 and 10133.16
to the Insurance Code, relating to health care coverage.
LEGISLATIVE COUNSEL'S DIGEST
SB 137, as amended, Hernandez. Health care coverage: provider
directories.
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. A willful violation
of the act is a crime. Existing law requires a health care service
plan to provide a list of contracting providers within a requesting
enrollee's or prospective enrollee's general geographic area.
Existing law also provides for the regulation of health insurers
by the Insurance Commissioner. Existing law requires insurers subject
to regulation by the commissioner to provide group policyholders
with a current roster of institutional and professional providers
under contract to provide services at alternative rates.
Existing law provides for the Medi-Cal program, which is
administered by the State Department of Health Care Services, under
which qualified low-income individuals receive health care services.
One of the methods by which Medi-Cal services are provided is
pursuant to contracts with various types of managed health care
plans.
Commencing February 1, 2016, this This
bill would require health care service plans, and insurers
subject to regulation by the commissioner for services at alternative
rates, to make an online provider directory available on its
Internet Web site, as specified.
Commencing, March 15, 2016, the This
bill would require the Department of Managed Health Care and the
Department of Insurance to jointly develop uniform provider directory
standards. Commencing September 15, 2016, or no later than
6 months after the provider directory standards are developed, this
The bill would require health care service
plans, plans with Medi-Cal managed care contracts, and insurers
subject to regulation by the commissioner for services at alternative
rates to make an online provider directory available on its Internet
Web site and to update the directory weekly.
, as specified. The bill would require a health care service plan or
insurer to reimburse an enrollee or insured for any
amount beyond what the enrollee, or insured would have paid for
in-network services, if the enrollee or insured reasonably relied on
the provider directory, as specified. By placing additional
requirements on health care service plans, the violation of which is
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 1367.26 of the
Health and Safety Code is repealed.
1367.26. (a) A health care service plan shall provide, upon
request, a list of the following contracting providers, within the
enrollee's or prospective enrollee's general geographic area:
(1) Primary care providers.
(2) Medical groups.
(3) Independent practice associations.
(4) Hospitals.
(5) All other available contracting physicians and surgeons,
psychologists, acupuncturists, optometrists, podiatrists,
chiropractors, licensed clinical social workers, marriage and family
therapists, professional clinical counselors, and nurse midwives to
the extent their services may be accessed and are covered through the
contract with the plan.
(b) This list shall indicate which providers have notified the
plan that they have closed practices or are otherwise not accepting
new patients at that time.
(c) The list shall indicate that it is subject to change without
notice and shall provide a telephone number that enrollees can
contact to obtain information regarding a particular provider. This
information shall include whether or not that provider has indicated
that he or she is accepting new patients.
(d) A health care service plan shall provide this information in
written form to its enrollees or prospective enrollees upon request.
A plan may, with the permission of the enrollee, satisfy the
requirements of this section by directing the enrollee or prospective
enrollee to the plan's provider listings on its Internet Web site.
Plans shall ensure that the information provided is updated at least
quarterly. A plan may satisfy this update requirement by providing an
insert or addendum to any existing provider listing. This
requirement shall not mandate a complete republishing of a plan's
provider directory.
(e) Each plan shall make information available, upon request,
concerning a contracting provider's professional degree, board
certifications, and any recognized subspeciality qualifications a
specialist may have.
(f) Nothing in this section shall prohibit a plan from requiring
its contracting providers, contracting provider groups, or
contracting specialized health care plans to satisfy these
requirements. If a plan delegates the responsibility of complying
with this section to its contracting providers, contracting provider
groups, or contracting specialized health care plans, the plan shall
ensure that the requirements of this section are met.
(g) Every health care service plan shall allow enrollees to
request the information required by this section through their
toll-free telephone number or in writing.
SECTION 1. SEC. 2. Section 1367.27
is added to the Health and Safety Code, to read:
1367.27. (a) Commencing February 1, 2016, a
A health care service plan shall make available
an online publish and maintain a provider
directory or directories that provide with
information on contracting providers that provide
deliver health care services to plan
the plan's enrollees, including those that
accept new patients, pursuant to the requirements of this
section and Section 1367.26. patients. A
provider directory shall not list or include information
on a provider that does not have a current is
not currently under contract with the plan.
(b) A health care service plan shall provide the
online directory or directories for the specific
network offered for each product using a consistent method of network
and product naming, numbering, or other classification method that
ensures the public, enrollees, potential enrollees, the department,
and other state or federal agencies can easily identify
which providers participate in which networks forwhich products. A
health plan shall use the same consistent naming, numbering, or
classification method in provider contracts and communications to
ensure that providers can identify the products and networks that
they are legally contracted to provide services in. The naming,
numbering, or classification shall be consistent across plans in
order to permit multiplan directories. the networks and
plan products in which a provider part icipates. By July
31, 2017, or six months after the date provider directory standards
are developed under this section, a health care service plan shall
use the naming, numbering, or classification method developed by the
department pursuant to subdivision (k).
(c) The (1) An
online provider directory or directories shall be available on the
plan's Internet Web site to the public, potential enrollees,
enrollees, and providers through a clearly identifiable link
or tab and in a manner that is accessible and searchable without any
requirement that a member of the public or potential enrollee
indicate intent to obtain coverage from the plan.
without any restrictions or limitations. The directory or
directories shall be available to the public without
requiring accessible without any requirement
that an individual seeking the directory information demonstrate
coverage with the plan, indicate interest in obtaining coverage
with the plan, provide a member identification or
policy number, provide any other identifying information, or create
or access an account.
(2) The online provider directory or directories shall be
accessible on the plan's public Internet Web site through a clearly
identifiable link or tab and in a manner that is accessible and
searchable by enrollees, potential enrollees, the public, and
providers. The plan's public Internet Web site shall allow provider
searches by name, practice address, distance from specified address,
California license number, National Provider Identifier number,
admitting privileges to an identified hospital, product, tier,
provider language, medical group or independent practice association,
hospital name, facility name, or clinic name, as appropriate.
(d) (1) A health care service plan shall allow enrollees,
potential enrollees, and members of the public to request a printed
copy of the provider directory or directories by contacting the plan
through the plan's toll-free telephone number, electronically, or in
writing. A printed copy of the provider directory or directories
shall include the information required in subdivisions (h) and (i).
The printed copy of the provider directory or directories shall be
provided to the enrollee by mail no later than 15 business days
following the date of the request and may be limited to the
geographic region in which the enrollee resides or works or intends
to reside or work.
(2) A health care service plan shall update its printed provider
directory or directories at least quarterly, or more frequently, if
required by federal law.
(d)
(e) The plan shall update the online provider directory
or directories, at least weekly, with any change to
contracting providers, including all of the following:
weekly, or more frequently, if required by federal law. Any change
in information concerning a listed contracting provider shall be
included in the updated version required by this subdivision. A
change in information includes, but is not limited to, any of the
following:
(1) Whether a contracting provider is no longer accepting new
patients for that product, or whether the contracting provider group
has identified that a provider of the group is no longer accepting
new patients.
(2) Whether the provider moved or relocated from
relocated out of the contracted service area of
the plan, has retired, or has otherwise ceased to practice,
in which case practice. In all of these cases,
the provider shall be deleted from the directory.
(3) Whether the provider is no longer contracted with the plan for
any reason, in which case the provider shall be deleted from the
directory.
(4) Whether the contracted provider is no longer under contract
for a particular product.
(5) Whether the provider's practice location or other information
required under subdivision (h) has changed.
(3)
(6) Whether the contracting provider group,
medical group, independent practice association, or
other group of providers, if any, has informed the plan that
the provider is no longer associated with the group and is no longer
under contract with the plan, in which case the provider shall be
deleted from the directory.
(7) Whether the contracting medical group, independent practice
association, or other group of providers has informed the plan that
the provider group is no longer under contract with the plan, in
which case any provider of the group that does not maintain an
independent contract with the plan shall be deleted from the
directory.
(4)
(8) When the plan identified a change is necessary
based on an enrollee complaint that a provider was not accepting new
patients, was otherwise not available, or whose contact information
was listed incorrectly.
(5)
(9) Any other relevant information that has come to the
attention of the plan affecting the content and accuracy of the
provider directory.
(e)
(f) The online provider directory or
directories shall include both an email address and a telephone
number for members of the public and providers to notify the plan if
the provider directory information appears to be inaccurate.
(f)
(g) The online provider directory
shall include the following disclosures informing enrollees that they
are entitled to both of the following:
(1) Language interpreter services, at no cost to the enrollee,
including how to obtain interpretation services.
(2) Full and equal access to covered services, including enrollees
with disabilities as required under the federal Americans with
Disabilities Act of 1990 and Section 504 of the Rehabilitation Act of
1973.
(h) A full service health care service plan and a specialized
mental health plan shall include all of the following information in
the provider directory or directories:
(1) The provider's name, practice location or locations, and
contact information.
(2) Type of practitioner.
(3) National Provider Identifier number.
(4) California license number and type of license.
(5) The area of specialty, including board certification, if any.
(6) The provider's office email address, if available.
(7) The name of all affiliated medical groups currently under
contract with the plan through which the provider sees enrollees.
(8) A listing for each of the following providers, facilities, and
services that are under contract with the plan:
(A) For physicians and surgeons, the medical group, and
affiliation or admitting privileges, if any, at hospitals contracted
with the plan.
(B) Nurse practitioners, physician assistants, psychologists,
acupuncturists, optometrists, podiatrists, chiropractors, licensed
clinical social workers, marriage and family therapists, professional
clinical counselors, substance abuse counselors, qualified autism
service providers, nurse midwives, and dentists.
(C) For federally qualified health centers or primary care
clinics, the name of the federally qualified health center or clinic.
(D) For any provider described in subparagraph (A) or (B) who is
employed by a federally qualified health center or primary care
clinic, and to the extent their services may be accessed and are
covered through the contract with the plan, the name of the provider,
and the name of the federally qualified health center or clinic.
(E) Facilities, including, but not limited to, general acute care
hospitals, skilled nursing facilities, urgent care clinics,
ambulatory surgery centers, inpatient hospice, residential care
facilities, and inpatient rehabilitation facilities.
(F) Pharmacies, clinical laboratories, imaging centers, and other
facilities providing contracted health care services.
(9) The provider directory may note that authorization or referral
may be required to access some providers.
(10) Non-English language, if any, spoken by a health care
provider or other medical professional as well as non-English
language spoken by a qualified medical interpreter, in accordance
with Section 1367.04, if any, on the provider's staff.
(11) Identification of providers who no longer accept new patients
for one or more of the plan's products or for all of the plan's
products.
(12) Network tier to which the provider is assigned, if the
provider is not in the lowest tier, as applicable. Nothing in this
section shall be construed to require the use of network tiers other
than contract and noncontracting tiers.
(13) All other information necessary to conduct a search pursuant
to paragraph (2) of subdivision (c).
(i) A vision, dental, or other specialized health care service
plan, except for a specialized mental health plan, shall include all
of the following information for each of the provider directories
used by the plan for its networks:
(1) The provider's name, practice location or locations, and
contact information.
(2) Type of practitioner.
(3) National Provider Identifier number.
(4) California license number and type of license, if applicable.
(5) The area of specialty, including board certification, or other
accreditation, if any.
(6) The provider's office email address, if available.
(7) The name of any affiliated medical group, independent practice
association, or specialty plan practice group currently under
contract with the plan through which the provider sees enrollees.
(8) The names of any allied health care professionals to the
extent there is a direct contract for those services covered through
the contract with the plan.
(9) Non-English language, if any, spoken by a health care provider
or other medical professional as well as non-English language spoken
by a qualified medical interpreter, in accordance with Section
1367.04, if any, on the provider's staff.
(j) If a contracting provider, or the representative of a
contracting provider, informs an enrollee or potential enrollee who
contacted the provider based on information in the provider directory
indicating that the provider was accepting new patients but the
provider is not accepting new patients, then the contract between the
plan and the provider shall require the provider to inform the plan
that the provider is not accepting new patients and direct the
enrollee or potential enrollee to the plan for additional assistance
in finding a provider and also to the department to inform it of the
possible inaccuracy in the provider directory. If an enrollee or
potential enrollee informs a plan of a possible inaccuracy in the
provider directory or directories, the plan shall immediately
investigate, and, if necessary, undertake corrective action within 30
business days to ensure the accuracy of the directory or
directories.
(k) (1) On or before December 31, 2016, the department shall
develop uniform provider directory standards for purposes of this
section. Those standards shall not be subject to the Administrative
Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1
of Division 3 of Title 2 of the Government Code), until January 1,
2021.
(2) In developing the standards under this subdivision, the
department shall seek input from interested parties and shall hold at
least one public meeting. The department shall take into
consideration any requirements for provider directories established
by the federal Centers for Medicare and Medicaid Services.
(3) By July 31, 2017, or six months after the date provider
directory standards are developed under this subdivision, whichever
occurs later, a plan shall use the standards developed by the
department for each product offered by the plan.
(l) A plan shall establish policies and procedures with regard to
the regular updating of its provider directory or directories,
including the weekly, quarterly, and annual updates required pursuant
to this section, or more frequently, if required by federal law or
guidance.
(m) The policies and procedures established under this subdivision
shall be submitted by a plan annually to the department for approval
and in a format described by the department pursuant to Section
1367.035.
(1) At a minimum, these policies and procedures shall include all
of the following:
(A) At least annually, the plan shall review and update the entire
provider directory or directories for each product offered.
(B) At least quarterly, the plan shall notify the contracted
provider or provider group, if applicable, of the information the
plan has in the directory or directories on the provider or provider
group contained in the directory, including a list of networks and
plan products that include the contracted provider or provider group.
The plan shall include with this notification instructions as to how
the provider or provider group can access and update the information
using the online interface required by subdivision (o).
(2) The plan shall require an affirmative response from the
provider or provider group acknowledging that the notification was
received. The provider or provider group shall attest that the
information in the provider directory is current and accurate or
update the information required to be in the directory pursuant to
this section, including whether or not the provider or provider group
is accepting new patients for each plan product.
(3) If the plan does not receive an affirmative response and
attestation from the provider that the information is current and
accurate or, as an alternative, updates information required to be in
the directory pursuant to this section, within 30 business days, the
plan shall take investigatory actions as outlined in subdivision (q)
to verify whether the provider's information is correct or requires
updates. The plan shall complete its investigation and make any
required corrections or updates to the provider directory based on
its investigation within 30 days from the date the provider was
required to provide the affirmative response to the plan. If, at the
completion of its investigation, the plan is unable to verify whether
the provider's information is correct or requires updates, the
provider shall be removed from the directory. A plan shall notify the
provider 10 days in advance of removal that the provider will be
removed from the directory.
(n) This section does not prohibit a plan from requiring its
risk-bearing organizations or contracting specialized health care
plans to satisfy the requirements of this section. If a plan
delegates the responsibility of complying with this section to its
risk-bearing organizations or contracting specialized health care
plans, the plan shall ensure that the requirements of this section
are met. A plan shall retain responsibility for the implementation of
this section, unless that delegated responsibility has been
separately negotiated and specifically documented in written
contracts between the plan and a risk-bearing organization or
contracting specialized health care plan.
(o) Every health care service plan shall ensure processes are in
place to allow providers to promptly verify or submit changes to the
information required to be in the directory pursuant to this section.
Those processes shall, at a minimum, include an online interface for
providers to submit verification or changes electronically and shall
allow providers to receive an acknowledgment of receipt from the
health care service plan. Providers shall verify or submit changes to
information required to be in the directory pursuant to this section
using the process required by the health plan.
(p) The plan shall establish and maintain a process for enrollees,
potential enrollees, other providers, and the public to identify and
report possible inaccurate, incomplete, confusing, or misleading
information currently listed in the plan's provider directory or
directories. These processes shall, at a minimum, include a telephone
number and a dedicated email address at which the plan will accept
these reports, as well as a hyperlink on the plan's provider
directory Internet Web page linking to a form where the information
can be reported directly to the plan through its Internet Web site.
(q) (1) Whenever a health care service plan receives a report
indicating that information listed in its provider directory or
directories is inaccurate, incomplete, confusing, or misleading, the
plan shall immediately investigate the reported inaccuracy and, no
later than 30 days following receipt of the communication, either
verify the accuracy of the information or update the information in
its provider directory or directories, as applicable.
(2) When investigating a communication regarding its provider
directory or directories, the plan shall, at a minimum, do the
following:
(A) Contact the affected provider no later than five business days
following receipt of the communication.
(B) Document the receipt and outcome of each communication. The
documentation shall include the provider's name, location, and a
description of the plan's investigation, the outcome of the
investigation, and any changes or updates made to its provider
directory or directories.
(C) If changes to a plan's provider directory or directories are
required as a result of the plan's investigation, the changes to the
online provider directory shall be made no later than the next
scheduled weekly update, or the update immediately following that
update, or sooner if required by federal law or regulations. For
printed provider directories, the change shall be made no later than
the next monthly quarterly update, or the monthly quarterly update
immediately following that update.
(r) Notwithstanding Sections 1371 and 1371.35, a plan may delay
payment or reimbursement to a provider who has not responded to the
plan's attempts to verify the provider's information. The plan may
delay payment or reimbursement for up to 45 business days in addition
to the timeframes for provider reimbursement pursuant to Sections
1371 and 1371.35. A plan may terminate a contract for a pattern or
repeated failure of the provider or provider group to alert the plan
to a change in the information required to be in the directory
pursuant to this section.
(s) (1) In circumstances where the department finds that an
enrollee reasonably relied upon inaccurate, incomplete, confusing, or
misleading information contained in a health plan's provider
directory or directories, the department may require the health plan
to provide coverage for all covered health care services provided to
the enrollee and to reimburse the enrollee for any amount beyond what
the enrollee would have paid, had the services been delivered by an
in-network provider under the enrollee's plan contract. Prior to
requiring reimbursement in these circumstances, the department must
conclude that the services received by the enrollee were covered
services under the enrollee's plan contract. In those circumstances,
the fact that the services were rendered or delivered by a
noncontracting or out-of-plan provider shall not be used as a basis
to deny reimbursement to the enrollee.
(2) In circumstances where an enrollee in the individual market
reasonably relied upon inaccurate, incomplete, confusing, or
misleading information contained in a health plan's provider
directory or directories, the plan shall inform the enrollee of the
special enrollment period available under subparagraph (E) of
paragraph (1) of subdivision (d) of Section 1399.845.
(3) "Risk-bearing
organization" shall have the same meaning as defined in subdivision
(g) of Section 1375.4.
(t) This section shall apply to plans with Medi-Cal managed care
contracts with the State Department of Health Care Services pursuant
to Chapter 7 (commencing with Section 14000) or Chapter 8 (commencing
with Section 14200) of the Welfare and Institutions Code to the
extent consistent with federal law and guidance.
(u) A health plan that contracts with multiple employer welfare
agreements regulated pursuant to Article 4.7 (commencing with Section
742.20) of Chapter 1 of Part 2 of Division 1 of the Insurance Code
shall meet the requirements of this section.
(v) Nothing in this section shall be construed to alter a provider'
s obligation to provide health care services to an enrollee pursuant
to the provider's contract with the plan.
SEC. 2. Section 1367.28 is added to the Health
and Safety Code, to read:
1367.28. (a) (1) By March 15, 2016, the department and the
Department of Insurance shall jointly develop uniform provider
directory standards consistent with this section. These standards
shall also require directories to be aggregated and searchable to
determine the plan with which a physician or other provider is
contracted.
(2) The department and the Department of Insurance shall seek
input from interested parties, including holding at least one public
meeting. In developing the directory standards, the department shall
take into consideration any requirements for provider directories
established by the federal Centers for Medicare and Medicaid
Services.
(3) By September 15, 2016, or no later than six months after the
date that provider directory standards are developed a plan shall use
the developed standards for each product offered by the plan.
(4) The uniform provider directory standards shall require the
plan's public Internet Web site to allow for provider searches by
name, practice address, National Provider Identifier number,
California license, facility or identification number, product, tier,
provider language, medical group, or independent practice
association, hospital, or clinic, as appropriate.
(b) A full service health care service plan and a specialized
mental health plan shall include all of the following information in
the online provider directory or directories:
(1) The provider's name, practice location or locations, and
contact information.
(2) Type of practitioner.
(3) National Provider Identifier number.
(4) California license number and type of license.
(5) The area of specialty, including board certification, if any.
(6) (A) For physicians, the medical group, if any.
(B) Nurse practitioners, physician assistants, psychologists,
acupuncturists, optometrists, podiatrists, chiropractors, licensed
clinical social workers, marriage and family therapists, professional
clinical counselors, nurse midwives, and dentists to the extent
their services may be accessed and are covered through the contract
with the plan. The plan may specify in the online provider directory
or directories that authorization or referral may be required to
access some providers.
(C) For federally qualified health centers or primary care
clinics, the name of the federally qualified health center or clinic.
(D) For any provider described in subparagraph (A) or (B) who is
employed by a federally qualified health center or primary care
clinic, and to the extent their services may be accessed and are
covered through the contract with the plan, the name of the provider,
and the name of the federally qualified health center or clinic.
(E) Pharmacies.
(F) Skilled nursing facilities.
(G) Urgent care clinics.
(7) Hospital affiliation or admitting privileges, if any, for
physicians and other health professionals contracted with the plan
whose scope of services for the plan include admitting patients and
who have admitting privileges at a contracted hospital.
(8) Non-English language, if any, spoken by a health care provider
or other medical professional as well as non-English language spoken
by a skilled medical interpreter, if any, on the provider's staff.
(9) Whether a provider is accepting new patients with the product
selected by the enrollee or potential enrollee.
(10) Network tier to which the provider is assigned, if the
participating provider has been divided into subgroupings
differentiated by the health plan according to enrollee cost-sharing
levels. Nothing in this section shall be construed to require the use
of network tiers other than contract and noncontracting tiers.
(11) A disclosure that enrollees are entitled to full and equal
access to covered services, including enrollees with disabilities as
required under the federal Americans with Disabilities Act of 1990
and Section 504 of the Rehabilitation Act of 1973.
(12) A disclosure that enrollees are entitled to language
interpreter services at no cost to the enrollee, including how to
obtain interpretation services.
(13) All other information necessary to conduct a search pursuant
to subparagraph (A) of paragraph (4) of subdivision (a).
(c) A vision, dental and other specialized health care service
plan, except for a specialized mental health plan, shall include all
of the following information for each of the online provider
directories used by the plan for its networks:
(1) The provider's name, practice location or locations, and
contact information.
(2) Type of practitioner.
(3) National Provider Identifier number.
(4) California license number and type of license.
(5) The area of specialty, including board certification, if any.
(6) If participating in a group practice, the name of the group
practice.
(7) The names of any allied health care professionals to the
extent there is a direct contract for those services covered through
the contract with the plan.
(8) Non-English language, if any, spoken by a health care provider
or other medical professional as well as non-English language spoken
by a skilled medical interpreter, if any, on the provider's staff.
(9) Whether a provider is accepting new patients enrolled in the
product that the directory applies to.
(10) A disclosure that enrollees are entitled to full and equal
access to covered services, including enrollees with disabilities as
required under the federal Americans with Disabilities Act of 1990
and Section 504 of the Rehabilitation Act of 1973.
(11) A disclosure that enrollees are entitled to language
interpreter services at no cost to the enrollee, including how to
obtain interpretation services.
(d) (1) The plan shall provide the online directory or directories
to the department in a format and manner to be specified by the
department.
(2) The plan shall demonstrate no less than quarterly to the
department that the information provided in the provider directory or
directories is consistent with the information required under
Sections 1367.03 and 1367.035, and other provisions of this chapter.
The plan shall ensure that other information reported to the
department is consistent with the information provided to enrollees,
potential enrollees, and the department pursuant to this section.
(3) The plan shall demonstrate to the department that enrollees or
potential enrollees seeking a provider that is contracted with the
network for a particular product can identify these providers and
that the provider is accepting new patients. The plan shall ensure
that the accuracy of the provider directory meets or exceeds 95
percent with regard to the participation of providers in the network,
the extent to which the provider is accepting new patients, and if
any non-English language is spoken by the provider or other medical
professionals, as well as non-English language spoken by a skilled
medical interpreter, if any, on the provider's staff.
(4) The plan shall contact any provider which is listed in the
provider directory and which has not submitted a claim within the
past six months for primary care providers, or twelve months for
specialty care providers, to determine whether the provider is
accepting patients or referrals from the plan, if claims are paid by
the plan. If claims are not paid by the plan, the plan shall contact
any provider that is listed in the provider directory who has not
submitted encounter data within the past six months for primary care
providers, or 12 months without encounter data for a specialty care
provider. If the provider does not respond within 30 days, the plan
shall remove the provider from the provider directory. A plan is not
required to terminate a provider who is removed from the directory
according to this paragraph. This requirement does not apply to
claims or encounter data from new primary care providers in the first
six months, or new specialty care providers in the first 12 months,
of the contract. This paragraph shall not apply if a provider has
affirmatively responded under the requirements of subdivision (h)
that the provider information is accurate and the provider is
continuing to participate in the network.
(e) If a contracting provider, or the representative of a
contracting provider, informs an enrollee or potential enrollee that
the provider is not accepting new patients, the contract between the
plan and the provider shall require the provider to inform the plan
that the provider is not accepting new patients and direct the
enrollee or potential enrollee to the plan for additional assistance
in finding a provider and also to the department to inform it of the
possible inaccuracy in the provider directory. If an enrollee or
potential enrollee informs a plan of a possible inaccuracy in the
provider directory or directories, the plan shall immediately
investigate and undertake corrective action within 30 business days
to ensure the accuracy of the directory or directories.
(f) This section does not prohibit a plan from requiring its
contracting providers, contracting provider groups, or contracting
specialized health care plans to satisfy the requirements of this
section. If a plan delegates the responsibility of complying with
this section to its contracting providers, contracting provider
groups, or contracting specialized health care plans, the plan shall
ensure that the requirements of this section are met.
(g) Every health care service plan shall ensure processes are in
place to allow providers to promptly verify or submit changes to the
information required to be in the directory pursuant to this section.
Those processes shall, at a minimum, include an online interface for
providers to submit verification or changes electronically and shall
allow providers to receive an acknowledgment of receipt from the
health care service plan. Providers shall verify or submit changes to
information required to be in the directory pursuant to this section
using the process required by the health plan.
(h) (1) At least every six months the plan shall notify the
contracted provider or provider group of the information on the
provider or provider group contained in the directory including a
list of each product marketed by the plan for the network. The plan
shall include with this notification instructions as to how to access
and update the information using the online interface in subdivision
(g).
(2) The plan shall require an affirmative response from the
provider or provider group acknowledging that the notification was
received and attesting that the information in the provider directory
is current and accurate. The provider shall update the information
required to be in the directory pursuant to this section, including
whether or not the provider or provider group is accepting new
patients for each product.
(3) If the plan does not receive an affirmative response and
attestation from the provider within 30 business days, the provider
shall be removed from the directory.
(i) Every health care service plan shall allow enrollees to
request the information required by this section through their
toll-free telephone number, electronically, or in writing. On request
of an enrollee or potential enrollee, the plan shall provide the
provider directory in printed form. The information provided in
printed form may be limited to the geographic region in which the
enrollee or potential enrollee resides or intends to reside.
(j) Notwithstanding the provisions of Section 1371, a plan may use
reasonable compliance methods, such as delaying payment or
reimbursement to a provider who has not responded or removal of the
provider from other directories only until the plan receives an
affirmative response and attestation from the provider. A plan may
terminate a contract for a pattern or repeated failure of the
provider or provider group to alert the plan to a change in the
information required to be in the directory pursuant to this section.
A plan may not impose any compliance method pursuant to this
subdivision without first providing written notice to the provider.
(k) This section shall apply to plans with Medi-Cal managed care
contracts with the State Department of Health Care Services pursuant
to Chapter 7 (commencing with Section 14000) or Chapter 8 (commencing
with Section 14200) of the Welfare and Institutions Code to the
extent consistent with federal law and guidance.
(l) A health plan that contracts with multiple employer welfare
agreements regulated pursuant to Article 4.7 (commencing with Section
742.20) of Chapter 1 of Part 2 of Division 1 of the Insurance Code
shall meet the requirements of this section.
SEC. 3. Section 10133.15 is added to the Insurance Code, to read:
10133.15. (a) Commencing February 1, 2016, a
A health insurer that contracts with providers for
alternative rates of payment pursuant to Section 10133 shall
make available an online publish and maintain
provider directory or directories that provide
with information on contracting providers that
provide deliver health care services to
insureds, the insurer's insureds, including
those that accept new patients pursuant to the requirements
of this section and Section 10133.1. patients. A
provider directory shall not list or include information
on a provider that does not have a current is
not currently under contract with the insurer.
(b) An insurer shall provide the online directory or directories
for the specific network offered for each product using a consistent
method of network and product naming, numbering, or other
classification method that ensures the public, insureds, potential
insureds, the department, and other state or federal agencies can
easily identify which providers participate in which
networks for which products. An insurer shall use the same consistent
naming, numbering, or classification method in provider contracts
and communications to ensure that providers can identify the products
and networks that they are legally contracted to provide services
in. The naming, numbering, or classification shall be consistent
across products in order to permit multiplan directories.
the networks and insurer products in which a provider
participates. By July 31, 2017, or six months after the date provider
directory standards are developed under this section, an insurer
shall use the naming, numbering, or classification method developed
by the department pursuant to subdivision (k).
(c) The (1) An
online provider directory or directories shall be available on the
insurer's Internet Web site to the public, potential insureds,
insureds, and providers through a clearly identifiable link
or tab and in a manner that is accessible and searchable without any
requirement that a member of the public or potential insureds
indicate intent to obtain coverage from the insurer.
without any restrictions or limitations. The directory or
directories shall be available to the public without
requiring accessible without any requirement
that an individual seeking the directory information demonstrate
coverage with the insurer, indicate interest in obtaining
coverage with the insurer, provide a member identification
or policy number, provide any other identifying information,
or create or access an account.
(2) The online provider directory or directories shall be
accessible on the insurer's public Internet Web site through a
clearly identifiable link or tab and in a manner that is accessible
and searchable by insureds, potential insureds, the public, and
providers. The insurer's public Internet Web site shall allow
provider searches by name, practice address, distance from specified
address, California license number, National Provider Identifier
number, admitting privileges to an identified hospital, product,
tier, provider language, medical group or independent practice
association, hospital name, facility name, or clinic name, as
appropriate.
(d) (1) A health insurer shall allow insureds, potential insureds,
and members of the public to request a printed copy of the provider
directory or directories by contacting the insurer through the
insurer's toll-free telephone number, electronically, or in writing.
A printed copy of the provider directory or directories shall include
the information required in subdivisions (h) and (i). The printed
copy of the provider directory or directories shall be provided to
the insured by mail no later than 15 business days following the date
of the request and may be limited to the geographic region in which
the insured resides or works or intends to reside or work.
(2) A health insurer shall update its printed provider directory
or directories at least quarterly, or more frequently, if required by
federal law.
(d)
(e) The insurer shall update the online provider
directory or directories, at least weekly, with any change
to contracting providers, including all of the following:
weekly, or more frequently, if required by federal law. Any
change in information concerning a listed contracting
provider shall be included in the updated version required by this
subdivision. A change in information includes, but is not limited to,
any of the following:
(1) Whether a contracting provider is no longer accepting new
patients for that product, or whether the contracting provider group
has identified that a provider of the group is no longer accepting
new patients.
(2) Whether the provider moved or relocated from
relocated out of the contracted service area of
the insurer, or has retired or has otherwise ceased to
practice, in which case practice. In all of these
cases, the provider shall be deleted from the directory.
(3) Whether the provider is no longer contracted with the insurer
for any reason, in which case the provider shall be deleted from the
directory.
(4) Whether the contracted provider is no longer under contract
for a particular product.
(5) Whether the provider's practice location or other information
required under subdivision (h) has changed.
(3)
(6) Whether the contracting provider group,
medical group, independent practice association, or
other group of providers, if any, has informed the insurer that
the provider is no longer associated with the group and is no longer
under contract with the plan, insurer,
in which case the provider shall be deleted from the directory.
(7) Whether the contracting medical group, independent practice
association, or other group of providers has informed the insurer
that the provider group is no longer under contract with the insurer,
in which case any provider of the group that does not maintain an
independent contract with the insurer shall be deleted from the
directory.
(4)
(8) When the plan insurer
identified a change is necessary based on an insured complaint that
a provider was not accepting new patients, was otherwise not
available, or whose contact information was listed incorrectly.
(5)
(9) Any other relevant information that has come to the
attention of the product affecting the content and accuracy of the
provider directory.
(e)
(f) The online provider directory or
directories shall include both an email address and a telephone
number for members of the public and providers to notify the insurer
if the provider directory information appears to be inaccurate.
(f)
(g) The online provider directory
shall include the following disclosures informing insureds that they
are entitled to both of the following:
(1) Language interpreter services, at no cost to the insured,
including how to obtain interpretation services.
(2) Full and equal access to covered services, including insureds
with disabilities as required under the federal Americans with
Disabilities Act of 1990 and Section 504 of the Rehabilitation Act of
1973.
(h) The health insurer and a specialized mental health insurer
shall include all of the following information in the provider
directory or directories:
(1) The provider's name, practice location or locations, and
contact information.
(2) Type of practitioner.
(3) National Provider Identifier number.
(4) California license number and type of license.
(5) The area of specialty, including board certification, if any.
(6) The provider's office email address, if available.
(7) The name of all affiliated medical groups currently under
contract with the insurer through which the provider sees enrollees.
(8) A listing for each of the following providers, facilities, and
services that are under contract with the insurer:
(A) For physicians and surgeons, the medical group, and
affiliation or admitting privileges, if any, at hospitals contracted
with the insurer.
(B) Nurse practitioners, physician assistants, psychologists,
acupuncturists, optometrists, podiatrists, chiropractors, licensed
clinical social workers, marriage and family therapists, professional
clinical counselors, substance abuse counselors, qualified autism
service providers, nurse midwives, and dentists.
(C) For federally qualified health centers or primary care
clinics, the name of the federally qualified health center or clinic.
(D) For any provider described in subparagraph (A) or (B) who is
employed by a federally qualified health center or primary care
clinic, and to the extent their services may be accessed and are
covered through the contract with the insurer, the name of the
provider, and the name of the federally qualified health center or
clinic.
(E) Facilities, including but not limited to, general acute care
hospitals, skilled nursing facilities, urgent care clinics,
ambulatory surgery centers, inpatient hospice, residential care
facilities, and inpatient rehabilitation facilities.
(F) Pharmacies, clinical laboratories, imaging centers, and other
facilities providing contracted health care services.
(9) The provider directory may note that authorization or referral
may be required to access some providers.
(10) Non-English language, if any, spoken by a health care
provider or other medical professional as well as non-English
language spoken by a qualified medical interpreter, in accordance
with Section 1367.04 of the Health and Safety Code, if any, on the
provider's staff.
(11) Identification of providers who no longer accept new patients
for one or more of the insurer's products or for all of the insurer'
s products.
(12) Network tier to which the provider is assigned, if the
provider is not in the lowest tier, as applicable. Nothing in this
section shall be construed to
require the use of network tiers other than contract and
noncontracting tiers.
(13) All other information necessary to conduct a search pursuant
to paragraph (2) of subdivision (c).
(i) A vision, dental, or other specialized insurer, except for a
specialized mental health insurer, shall include all of the following
information for each of the provider directories used by the insurer
for its networks:
(1) The provider's name, practice location or locations, and
contact information.
(2) Type of practitioner.
(3) National Provider Identifier number.
(4) California license number and type of license, if applicable.
(5) The area of specialty, including board certification, or other
accreditation, if any.
(6) The provider's office email address, if available.
(7) The name of any affiliated medical group, independent practice
association, or specialty insurer practice group currently under
contract with the insurer through which the provider sees insureds.
(8) The names of any allied health care professionals to the
extent there is a direct contract for those services covered through
the contract with the insurer.
(9) Non-English language, if any, spoken by a health care provider
or other medical professional as well as non-English language spoken
by a qualified medical interpreter, in accordance with Section
1367.04 of the Health and Safety Code, if any, on the provider's
staff.
(j) If a contracting provider, or the representative of a
contracting provider, informs an insured or potential insured who
contacted the provider based on information in the provider directory
indicating that the provider was accepting new patients but the
provider is not accepting new patients, then the contract between the
insurer and the provider shall require the provider to inform the
insurer that the provider is not accepting new patients and direct
the insured or potential insured to the insurer for additional
assistance in finding a provider and also to the department to inform
it of the possible inaccuracy in the provider directory. If an
insured or potential insured informs an insurer of a possible
inaccuracy in the provider directory or directories, the insurer
shall immediately investigate and, if necessary, undertake corrective
action within 30 business days to ensure the accuracy of the
directory or directories.
(k) (1) On or before December 31, 2016, the department shall
develop uniform provider directory standards for purposes of this
section. Those standards shall not be subject to the Administrative
Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1
of Division 3 of Title 2 of the Government Code), until January 1,
2021.
(2) In developing the standards under this subdivision, the
department shall seek input from interested parties and shall hold at
least one public meeting. The department shall take into
consideration any requirements for provider directories established
by the federal Centers for Medicare and Medicaid Services.
(3) By July 31, 2017, or six months after the date provider
directory standards are developed under this subdivision, whichever
occurs later, an insurer shall use the standards developed by the
department for each product offered by the insurer.
(l) An insurer shall establish policies and procedures with regard
to the regular updating of its provider directory or directories,
including the weekly, quarterly, and annual updates required pursuant
to this section, or more frequently, if required by federal law or
guidance.
(m) The policies and procedures established under this subdivision
shall be submitted by an insurer annually to the department for
approval and in a format described by the department.
(1) At a minimum, these policies and procedures shall include all
of the following:
(A) At least annually, the insurer shall review and update the
entire provider directory or directories for each product offered.
(B) At least quarterly, the insurer shall notify the contracted
provider or provider group, if applicable, of the information the
insurer has in the directory or directories on the provider or
provider group contained in the directory, including a list of
networks and insurer products that include the contracted provider or
provider group. The insurer shall include with this notification
instructions as to how the provider or provider group can access and
update the information using the online interface required by
subdivision (o).
(2) The insurer shall require an affirmative response from the
provider or provider group acknowledging that the notification was
received. The provider or provider group shall attest that the
information in the provider directory is current and accurate or
update the information required to be in the directory pursuant to
this section, including whether or not the provider or provider group
is accepting new patients for each insurer product.
(3) If the insurer does not receive an affirmative response and
attestation from the provider that the information is current and
accurate or, as an alternative, updates information required to be in
the directory pursuant to this section, within 30 business days, the
insurer shall take investigatory actions as outlined in subdivision
(q) to verify whether the provider's information is correct or
requires updates. The insurer shall complete its investigation and
make any required corrections or updates to the provider directory
based on its investigation within 30 days from the date the provider
was required to provide the affirmative response to the insurer. If,
at the completion of its investigation, the insurer is unable to
verify whether the provider's information is correct or requires
updates, the provider shall be removed from the directory. An insurer
shall notify the provider 10 days in advance of removal that the
provider will be removed from the directory.
(n) This section does not prohibit an insurer from requiring its
risk-bearing organizations or contracting specialized health insurers
to satisfy the requirements of this section. If an insurer delegates
the responsibility of complying with this section to its
risk-bearing organizations or contracting specialized health
insurers, the insurer shall ensure that the requirements of this
section are met. An insurer shall retain responsibility for the
implementation of this section, unless that delegated responsibility
has been separately negotiated and specifically documented in written
contracts between the insurer and a risk-bearing organization or
contracting specialized health insurer.
(o) Every health insurer shall ensure processes are in place to
allow providers to promptly verify or submit changes to the
information required to be in the directory pursuant to this section.
Those processes shall, at a minimum, include an online interface for
providers to submit verification or changes electronically and shall
allow providers to receive an acknowledgment of receipt from the
health insurer. Providers shall verify or submit changes to
information required to be in the directory pursuant to this section
using the process required by the health insurer.
(p) The insurer shall establish and maintain a process for
insureds, potential insureds, other providers, and the public to
identify and report possible inaccurate, incomplete, confusing, or
misleading information currently listed in the insurer's provider
directory or directories. These processes shall, at a minimum,
include a telephone number and a dedicated email address at which the
insurer will accept these reports, as well as a hyperlink on the
insurer's provider directory Internet Web page linking to a form
where the information can be reported directly to the insurer through
its Internet Web site.
(q) (1) Whenever a health insurer receives a report indicating
that information listed in its provider directory or directories is
inaccurate, incomplete, confusing, or misleading, the insurer shall
immediately investigate the reported inaccuracy and, no later than 30
days following receipt of the communication, either verify the
accuracy of the information or update the information in its provider
directory or directories, as applicable.
(2) When investigating a communication regarding its provider
directory or directories, the insurer shall, at a minimum, do the
following:
(A) Contact the affected provider no later than five business days
following receipt of the communication.
(B) Document the receipt and outcome of each communication. The
documentation shall include the provider's name, location, and a
description of the insurer's investigation, the outcome of the
investigation, and any changes or updates made to its provider
directory or directories.
(C) If changes to an insurer's provider directory or directories
are required as a result of the insurer's investigation, the changes
to the online provider directory shall be made no later than the next
scheduled weekly update, or the update immediately following that
update, or sooner if required by federal law or regulations. For
printed provider directories, the change shall be made no later than
the next monthly quarterly update, or the monthly quarterly update
immediately following that update.
(r) Notwithstanding Section 10123.13, an insurer may delay payment
or reimbursement to a provider who has not responded to the insurer'
s attempts to verify the provider's information. The insurer may
delay payment or reimbursement for up to 45 business days in addition
to the timeframes for provider reimbursement pursuant to Section
10123.13. An insurer may terminate a contract for a pattern or
repeated failure of the provider or provider group to alert the
insurer to a change in the information required to be in the
directory pursuant to this section.
(s) (1) In circumstances where the department finds that an
insured reasonably relied upon inaccurate, incomplete, confusing, or
misleading information contained in an insurer's provider directory
or directories, the department may require the insurer to provide
coverage for all covered health care services provided to the insured
and to reimburse the insured for any amount beyond what the insured
would have paid, had the services been delivered by an in-network
provider under the insured's insurance contract. Prior to requiring
reimbursement in these circumstances, the department must conclude
that the services received by the insured were covered services under
the insured's insurance contract. In those circumstances, the fact
that the services were rendered or delivered by a noncontracting or
out-of-network provider shall not be used as a basis to deny
reimbursement to the insured.
(2) In circumstances where an insured in the individual market
reasonably relied upon inaccurate, incomplete, confusing, or
misleading information contained in an insurer's provider directory
or directories, the insurer shall inform the insured of the special
enrollment period available under subparagraph (E) of paragraph (1)
of subdivision (d) of Section 10965.3.
(3) "Risk-bearing organization" shall have the same meaning as
defined in subdivision (g) of Section 1375.4 of the Health and Safety
Code.
(t) An insurer that contracts with multiple employer welfare
agreements regulated pursuant to Article 4.7 (commencing with Section
742.20) of Chapter 1 of Part 2 of Division 1 shall meet the
requirements of this section.
(u) Nothing in this section shall be construed to alter a provider'
s obligation to provide health care services to an insured pursuant
to the provider's contract with the insurer.
SEC. 4. Section 10133.16 is added to the
Insurance Code, to read:
10133.16. (a) (1) By March 15, 2016, the department and the
Department of Managed Health Care shall jointly develop uniform
provider directory standards consistent with this section. These
standards shall also require directories to be aggregated and
searchable to determine the insurer with which a physician or other
provider is contracted.
(2) The department and the Department of Managed Health Care shall
seek input from interested parties, including holding at least one
public meeting. In developing the directory standards, the department
shall take into consideration any requirements for provider
directories established by the federal Centers for Medicare and
Medicaid Services.
(3) By September 15, 2016, or no later than six months after the
date that provider directory standards are developed, an insurer
shall use the developed standards for each product offered by the
insurer.
(4) The uniform provider directory standards shall require the
insurer's public Internet Web site to allow for provider searches by
name, practice address, National Provider Identifier number,
California license number, facility or identification number,
product, tier, provider language, medical group, or independent
practice association, hospital, or clinic, as appropriate.
(b) The insurer and a specialized mental health insurer shall
include all of the following information in the online provider
directory or directories:
(1) The provider's name, practice location or locations, and
contact information.
(2) Type of practitioner.
(3) National Provider Identifier number.
(4) California license number and type of license.
(5) The area of specialty, including board certification, if any.
(6) (A) For physicians, the medical group, if any.
(B) Nurse practitioners, physician assistants, psychologists,
acupuncturists, optometrists, podiatrists, chiropractors, licensed
clinical social workers, marriage and family therapists, professional
clinical counselors, nurse midwives, and dentists to the extent
their services may be accessed and are covered through the contract
with the insurer. The insurer may specify in the provider directory
or directories that authorization or referral may be required to
access some providers.
(C) For federally qualified health centers or primary care
clinics, the name of the federally qualified health center or clinic.
(D) For any provider described in subparagraph (A) or (B) who is
employed by a federally qualified health center or primary care
clinic, and to the extent their services may be accessed and are
covered through the contract with the insurer, the name of the
provider, and the name of the federally qualified health center or
clinic.
(E) Pharmacies.
(F) Skilled nursing facilities.
(G) Urgent care clinics.
(7) Hospital affiliation or admitting privileges, if any, for
physicians and other health professionals contracted with the insurer
whose scope of services for the product include admitting patients
and who have admitting privileges at a contracted hospital.
(8) Non-English language, if any, spoken by a health care provider
or other medical professional as well as non-English language spoken
by a skilled medical interpreter, if any, on the provider's staff.
(9) Whether a provider is accepting new patients with the product
selected by the insured or potential insured.
(10) Network tier that the provider is assigned if the
participating provider has been divided into subgroupings
differentiated by the insurer according to insured cost-sharing
levels or quality scores. Nothing in this section shall be construed
to require the use of network tiers other than contract and
noncontracting tiers.
(11) A disclosure that insureds are entitled to full and equal
access to covered services, including insureds with disabilities as
required under the federal Americans with Disabilities Act of 1990
and Section 504 of the Rehabilitation Act of 1973.
(12) A disclosure that insureds are entitled to language
interpreter services at no cost to the insured, including how to
obtain interpretation services.
(13) All other information necessary to conduct a search pursuant
to subparagraph (A) of paragraph (4) of subdivision (a).
(c) A vision, dental, and other specialized insurer, except for a
specialized mental health insurer, shall include all of the following
information for each of the online provider directories used by the
insurer for its networks:
(1) The provider's name, practice location or locations, and
contact information.
(2) Type of practitioner.
(3) National Provider Identifier number.
(4) California license number and type of license.
(5) The area of specialty, including board certification, if any.
(6) If participating in a group practice, the name of the group
practice.
(7) The names of any allied health care professionals to the
extent there is a direct contract for those services covered through
the contract with the insurer.
(8) Non-English language, if any, spoken by a health care provider
or other medical professional as well as non-English language spoken
by a skilled medical interpreter, if any, on the provider's staff.
(9) Whether a provider is accepting new patients enrolled in the
product that the directory applies to.
(10) A disclosure that insureds are entitled to full and equal
access to covered services, including insureds with disabilities as
required under the federal Americans with Disabilities Act of 1990
and Section 504 of the Rehabilitation Act of 1973.
(11) A disclosure that insureds are entitled to language
interpreter services at no cost to the insured, including how to
obtain interpretation services.
(d) (1) The insurer shall provide the online directory or
directories to the department in a format and manner to be specified
by the department.
(2) The insurer shall demonstrate no less than quarterly to the
department that the information provided in the provider directory or
directories is consistent with the information required under
Section 10133.5 and other provisions of this part. The insurer shall
ensure that other information reported to the department is
consistent with the information provided to insureds, potential
insureds, and the department pursuant to this section.
(3) The insurer shall demonstrate to the department that insureds
or potential insureds seeking a provider that is contracted with the
network for a particular product can identify these providers and
that the provider is accepting new patients. The insurer shall ensure
that the accuracy of the provider directory meets or exceeds 95
percent with regard to the participation of providers in the network,
the extent to which the provider is accepting new patients, as well
as non-English language spoken by a skilled medical interpreter, if
any, on the provider's staff.
(4) The insurer shall contact any provider which is listed in the
provider directory and which has not submitted a claim within the
past six months for primary care providers, or 12 months for
specialty care providers, to determine whether the provider is
accepting patients or referrals from the insurer, if claims are paid
by the insurer. If the provider does not respond within 30 days, the
insurer shall remove the provider from the provider directory. An
insurer is not required to terminate a provider who is removed from
the directory according to this paragraph. This requirement does not
apply to claims or claim data from new primary care providers in the
first six months, or new specialty care providers in the first 12
months, of the contract. This paragraph shall not apply if a provider
has affirmatively responded under the requirements of subdivision
(h) that the provider information is accurate and the provider is
continuing to participate in the network.
(e) If a contracting provider, or the representative of a
contracting provider, informs an insured or potential insured that
the provider is not accepting new patients, the contract between the
insurer and the provider shall require the provider to inform the
insurer that the provider is not accepting new patients and direct
the insured or potential insured to the insurer for additional
assistance in finding a provider and also to the department to inform
it of the possible inaccuracy in the provider directory. If an
insured or potential insured informs an insurer of a possible
inaccuracy in the provider directory or directories, the insurer
shall immediately investigate and undertake corrective action within
30 business days to ensure the accuracy of the directory or
directories.
(f) This section does not prohibit an insurer from requiring its
contracting providers, contracting provider groups, or contracting
specialized health care plans to satisfy the requirements of this
section. If an insurer delegates the responsibility of complying with
this section to its contracting providers, contracting provider
groups, or contracting specialized health care plans, the insurer
shall ensure that the requirements of this section are met.
(g) Every insurer shall ensure processes are in place to allow
providers to promptly verify or submit changes to the information
required to be in the directory pursuant to this section. Those
processes shall, at a minimum, include an online interface for
providers to submit verification or changes electronically and shall
allow providers to receive an acknowledgment of receipt from the
health insurer. Providers shall verify or submit changes to
information required to be in the directory pursuant to this section
using the process required by the insurer.
(h) (1) At least once every six months the insurer shall notify
the contracted provider or provider group of the information on the
provider or provider group contained in the directory including a
list of each product marketed by the insurer for the network. The
insurer shall include with this notification, instructions as to how
to access and update the information using the online interface in
subdivision (g).
(2) The insurer shall require an affirmative response from the
provider or provider group acknowledging that the notification was
received and attesting that the information in the provider directory
is current and accurate. The provider shall update the information
required to be in the directory pursuant to this section, including
whether or not the provider or provider group is accepting new
patients for each product.
(3) If the insurer does not receive an affirmative response and
attestation from the provider within 30 business days, the provider
shall be removed from the directory.
(i) Every health insurer shall allow insureds to request the
information required by this section through their toll-free
telephone number, electronically, or in writing. On request of an
insured or potential insured, the insurer shall provide the provider
directory in printed form. The information provided in printed form
may be limited to the geographic region in which the insured or
potential insured resides or intends to reside.
(j) Notwithstanding the provisions of Section 10123.13, an insurer
may use reasonable compliance methods, such as delaying payment or
reimbursement to a provider who has not responded or removal of the
provider from other directories only until the plan receives an
affirmative response and attestation from the provider. An insurer
may terminate a
contract for a pattern or repeated failure of the provider or
provider group to alert the insurer to a change in the information
required to be in the directory pursuant to this section. An insurer
may not impose any compliance method pursuant to this subdivision
without first providing written notice to the provider.
(k) An insurer that contracts with multiple employer welfare
agreements regulated pursuant to Article 4.7 (commencing with Section
742.20) of Chapter 1 of Part 2 of Division 1 shall meet the
requirements of this section.
SEC. 5. SEC. 4. 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.
