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 AUGUST 31, 2015
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 Section 1367.27 to, and to repeal Section
1367.26 of, the Health and Safety Code, and to add Section 10133.15
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 health
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.
This bill bill, commencing July 1, 2016,
would require a health care service plans,
and insurers subject to regulation by the commissioner for services
at alternative rates, to plan, and a health insurer
that contracts with providers for alternative rates of payment, to
publish and maintain a provider directory or directories with
information on contracting providers that deliver health care
services to the plan's enrollees or the health insurer's insureds,
and would require the plan or health insurer to make an online
provider directory or directories available on
its the plan or health insurer's Internet Web
site, as specified.
This bill would require the Department of Managed Health Care and
the Department of Insurance to jointly develop uniform provider
directory standards. 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, as specified.
a health care service plan or health insurer to take
appropriate steps to ensure the accuracy of the information contained
in the plan or health insurer's directory or directories, and would
require the plan or health insurer, at least annually, to
review and update the entire provider directory or directories for
each product offered, as specified. The bill would require a plan or
insurer, at least weekly, to update its online provider directory or
directories, and would require a plan or insurer, at least quarterly,
to update its printed provider directory or directories. The
bill would require a health care service plan or health
insurer to reimburse an enrollee or insured for any amount beyond
what the enrollee, 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.
SEC. 2. Section 1367.27 is added to the Health and Safety Code, to
read:
1367.27. (a) A Commencing July 1, 2016, a
health care service plan shall publish and maintain a provider
directory or directories with information on contracting providers
that deliver health care services to the plan's enrollees, including
those that accept new patients. A provider directory shall not list
or include information on a provider that is not currently under
contract with the plan.
(b) A health care service plan shall provide the 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 the networks and plan products in which a provider
participates. By July 31, 2017, or six 12
months after the date provider directory standards are
developed under this section, subdivision
(k), whichever occurs later, a health care service plan shall
use the naming, numbering, or classification method developed by the
department pursuant to subdivision (k).
(c) (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 without any restrictions or
limitations. The directory or directories shall be 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 an identifiable link or tab and in a
manner that is accessible and searchable by enrollees, potential
enrollees, the public, and providers. The By
July 31, 2017, or twelve months after the date provider directory
standards are developed under subdivision (k), whichever occurs
later, the plan's public Internet Web site shall allow provider
searches by by, at a minimum, name,
practice address, distance from specified address,
city, ZIP Code, California license number, National
Provider Identifier number, admitting privileges to an identified
hospital, product, tier, provider language, medical group or
independent practice association, language or
languages, provider group, hospital name, facility name, or
clinic name, as appropriate.
(d) (1) A health care service plan shall allow enrollees,
potential enrollees, providers, 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
requester by mail postmarked no later than
15 five business days following the date
of the request and may be limited to the geographic region in which
the enrollee requester 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.
(e) (1) The plan shall update the online
provider directory or directories, at least 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,
law, when informed of and upon confirmation by the plan
of any of the following:
(1) Whether a
(A) 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 an individual provider within a provider group
is no longer accepting new patients.
(2) Whether the provider relocated out of the contracted service
area of the plan, has retired, or has otherwise ceased to 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
(B) A provider is no longer under
contract for a particular plan product.
(5) Whether the
(C) A provider's practice
location or other information required under subdivision (h) or
(i) has changed.
(6) Whether the contracting 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.
(8) When the plan identified
(D) Upon completion of the
investigation described in subdivision (o), 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.
(9) Any other relevant information that has come to the attention
of the plan affecting
(E) Any other information that affects
the content and or accuracy of
the provider directory. directory or
directories.
(2) Upon confirmation of any of the following, the plan shall
delete a provider from the directory or directories when:
(A) A provider has retired or otherwise has ceased to practice.
(B) A provider or provider group is no longer under contract with
the plan for any reason.
(C) The contracting provider group has informed the plan that the
provider is no longer associated with the provider group and is no
longer under contract with the plan.
(f) The 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. This information shall be disclosed
prominently in the directory or directories and on the plan's
Internet Web site.
(g) The provider directory or directories 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.
services in accordance with Section 1367.04.
(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 each affiliated
medical groups provider group currently
under contract with the plan through which the provider sees
enrollees.
(8) A listing for each of the following providers,
facilities, and services providers that are
under contract with the plan:
(A) For physicians and surgeons, the medical
provider 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, as defined in Section
1374.73, 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 or directories 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 some or all of the
plan's products or for all of the plan's products.
(12) Network The 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 directory or 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 each affiliated
medical group, independent practice association,
provider group or specialty plan practice group currently
under contract with the plan through which the provider sees
enrollees.
(8) The names of any each allied
health care professionals professional
to the extent there is a direct contract for those services covered
through the a contract with the plan.
(9) Non-English The 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.
(10) Identification of providers who no longer accept new patients
for some or all of the plan's products.
(11) All other applicable information necessary to conduct a
provider search pursuant to paragraph (2) of subdivision (c).
(j) (1) The contract between the plan and a provider shall include
a requirement that the provider inform the plan within five business
days when either of the following occur:
(A) The provider is not accepting new patients.
(B) If the provider had previously not accepted new patients, the
provider is currently accepting new patients.
(2) If a provider who is not accepting new patients is contacted
by an enrollee or potential enrollee seeking to become a new patient,
the provider shall direct the enrollee or potential enrollee to the
plan for additional assistance in finding a provider and the provider
shall provide information to the individual on how to contact the
department to report any inaccuracy with the plan's directory or
directories.
(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
(3) If an enrollee or potential
enrollee informs a plan of a possible inaccuracy in the provider
directory or directories, the plan shall immediately
promptly 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. to permit consistency in accordance
with subdivision (b) and paragraph (2) of subdivision (c) and
development of a multi-plan directory by another entity. 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. No
more than two revisions of those standards shall be exempt from the
Administrative Procedure Act (Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code)
pursuant to this subdivision.
(2) In developing the standards under this subdivision, the
department shall seek input from interested parties throughout
the process of developing the standards 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.
Services and the State Department of Health Care Services.
(3) By July 31, 2017, or six 12
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) (1) A plan shall take appropriate steps to ensure the accuracy
of the information concerning each provider listed in the plan's
provider directory or directories in accordance with this section,
and shall, at least annually, review and update the entire provider
directory or directories for each product offered. Each calendar year
the plan shall notify all contracted providers described in
subdivisions (h) and (i) as follows:
(A) For individual providers who are not affiliated with a
provider group described in subparagraph (A) or (B) of paragraph (8)
of subdivision (h) and providers described in subdivision (i), the
plan shall notify each provider at least once every six months.
(B) For all other providers described in subdivision (h) who are
not subject to the requirements of subparagraph (A), the plan shall
notify its contracted providers to ensure that all of the providers
are contacted by the plan at least once annually.
(2) The notification shall include all of the following:
(A) The information the plan has in its directory or directories
regarding the provider or provider group, including a list of
networks and plan products that include the contracted provider or
provider group.
(B) A statement that the failure to respond to the notification
may result in a delay of payment or reimbursement of a claim pursuant
to subdivision (p).
(C) Instructions on how the provider or provider group can update
the information in the provider directory or directories using the
online interface developed pursuant to subdivision (m).
(3) 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 confirm that the
information in the provider directory or directories is current and
accurate or update the information required to be in the directory or
directories pursuant to this section, including whether or not the
provider or provider group is accepting new patients for each plan
product.
(4) If the plan does not receive an affirmative response and
confirmation from the provider that the information is current and
accurate or, as an alternative, updates any information required to
be in the directory or directories pursuant to this section, within
30 business days, the plan shall take no more than 15 business days
to verify whether the provider's information is correct or requires
updates. The plan shall document the receipt and outcome of each
attempt to verify the information. If the plan is unable to verify
whether the provider's information is correct or requires updates,
the plan shall notify the provider 10 business days in advance of
removal that the provider will be removed from the provider directory
or directories. The provider shall be removed from the provider
directory or directories at the next required update of the provider
directory or directories after the 10-business day notice period. A
provider shall not be removed from the provider directory or
directories if he or she responds before the end of the 10-business
day notice period.
(l)
(m) 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)
(1) The policies and procedures established
described under this
subdivision (l) 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)
(2) 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
or directories 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 generate an
acknowledgment of receipt from the health care service plan.
Providers shall verify or submit changes to information required to
be in the directory or directories pursuant to this
section using the process required by the health care service
plan.
(p)
(3) 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
site linking to a form where the information
can be reported directly to the plan through its Internet Web site.
(n) (1) This section does not prohibit a plan from requiring its
provider groups or contracting specialized health care service plans
to provide information to the plan that is required by the plan to
satisfy the requirements of this section for each of the providers
that contract with the provider group or contracting specialized
health care service plan. This responsibility shall be specifically
documented in a written contract between the plan and the provider
group or contracting specialized health care service plan.
(2) If a plan requires its contracting provider groups or
contracting specialized health care service plans to provide the plan
with information described in paragraph (1), the plan shall continue
to retain responsibility for ensuring that the requirements of this
section are satisfied.
(q)
(o) (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
promptly investigate the reported inaccuracy and, no later
than 30 business days following receipt of the
communication, report, either verify the
accuracy of the information or update the information in its provider
directory or directories, as applicable.
(2) When investigating a communication
report 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.
report.
(B) Document the receipt and outcome of each
communication. report. 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 or directories 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
required update, or the monthly
quarterly update immediately following that update.
sooner if required by federal law or regulations.
(r) Notwithstanding
(p) (1)
Commencing July 1, 2017, no twithstanding Sections
1371 and 1371.35, a plan may delay payment or reimbursement
to a provider who has not responded owed to a provider
or provider group as specified in subparagraph (A) or (B), if the
provider or provider group fails to respond to the plan's
attempts to verify the provider's information. The
provider or provider group's information as required under
subdivision (l). The plan shall not delay payment unless it has
attempted to verify the provider's or provider group's information by
all means of communication available to the plan, including in
writing, electronically, or by telephone. A plan may seek to delay
payment or reimbursement owed to a provider or provider group only
after the 10-business day notice period described in paragraph (4) of
subdivision (l) has lapsed.
(A) For a provider or provider group
that receives compensation on a capitated or prepaid basis, 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
the next scheduled capitation payment for up to one calendar
month.
(B) For any claims payment made to a provider or provider group,
the plan may delay the claims payment for up to one calendar month
beginning on the first day of the following month.
(2) A plan shall notify the provider or provider group 10 business
days before it seeks to delay payment or reimbursement to a provider
or provider group pursuant to this subdivision. If the plan delays a
payment or reimbursement pursuant to this subdivision, the plan
shall reimburse the full amount of any payment or reimbursement
subject to delay to the provider or provider group no later than
three business days following the date on which the plan receives the
information required to be submitted by the provider or provider
group pursuant to subdivision (l).
(3) 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 or directories pursuant to
this section.
(4) With respect to plans with Medi-Cal managed care contracts
with the State Department of Health Care Services pursuant to Chapter
7 (commencing with Section 14000), Chapter 8 (commencing with
Section 14200), or Chapter 8.75 (commencing with Section 14591) of
the Welfare and Institutions Code, this subdivision shall be
implemented only to the extent consistent with federal law and
guidance.
(s) (1) In
(q ) In circumstances
where the department finds that an enrollee reasonably relied upon
materially 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 shall 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.
(r) Whenever a plan determines as a result of this section that
there has been a 10-percent change in the network for a product in a
region, the plan shall file an amendment to the plan application with
the department consistent with subdivision (f) of Section 1300.52 of
Title 28 of the California Code of Regulations.
(t)
(s) 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 14000), Chapter 8 (commencing with
Section 14200) 14200), or Chapter
8.75 (commencing with Section 14591) of the Welfare and
Institutions Code to the extent consistent with federal law and
guidance. guidance and state law guidance
issued after January 1, 2016. Notwithstanding any other provision to
the contrary in a plan contract with the State Department of Health
Care Services, and to the extent consistent with federal law and
guidance and state guidance issued after January 1, 2016, a Medi-Cal
managed care plan that complies with the requirements of this section
shall not be required to distribute a printed provider directory or
directories, except as required by paragraph (1) of subdivision (d).
(u)
(t) 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)
(u) 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.
(v) For purposes of this section, "provider group" means a medical
group, independent practice association, or other similar group of
providers.
SEC. 3. Section 10133.15 is added to the Insurance Code, to read:
10133.15. (a) A Commencing July 1, 2016,
a health insurer that contracts with providers for alternative
rates of payment pursuant to Section 10133 shall publish and maintain
provider directory or directories with information on contracting
providers that deliver health care services to the insurer's
insureds, including those that accept new patients. A provider
directory shall not list or include information on a provider that 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 the networks and insurer products in which a provider
participates. By July 31, 2017, or six 12
months after the date provider directory standards are
developed under this section, subdivision
(k), whichever occurs later, an insurer shall use the naming,
numbering, or classification method developed by the department
pursuant to subdivision (k).
(c) (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 without any restrictions or
limitations. The directory or directories shall be 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 an identifiable link or tab and in a
manner that is accessible and searchable by insureds, potential
insureds, the public, and providers. The By
July 1, 2017, or 12 months after the date provider directory
standards are devel oped under subdivision (k), whichever
occurs later, the insurer's public Internet Web site shall
allow provider searches by by, at a minimum,
name, practice address, distance from specified
address, city, ZIP Code, California license
number, National Provider Identifier number, admitting privileges to
an identified hospital, product, tier, provider language,
medical group or independent practice association,
language or languages, provider group, hospital name, facility
name, or clinic name, as appropriate.
(d) (1) A health An insurer shall
allow insureds, potential insureds, providers, 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 requester by mail
postmarked no later than 15 five
business days following the date of the request and may be limited to
the geographic region in which the insured
requester resides or works or intends to reside or work.
(2) A health An insurer shall update
its printed provider directory or directories at least quarterly, or
more frequently, if required by federal law.
(e) (1) The insurer shall update the online
provider directory or directories, at least 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,
law, when informed of and upon confirmation by the insurer of
any of the following:
(1) Whether a
(A) 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 an individual provider within a provider group
is no longer accepting new patients.
(2) Whether the provider relocated out of the contracted service
area of the insurer, or has retired or has otherwise ceased to
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
(B) A contracted provider is no
longer under contract for a particular product.
(5) Whether the
(C) A provider's practice
location or other information required under subdivision (h) or
(i) has changed.
(6) Whether the contracting 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 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.
(8) When the insurer identified
(D) Upon the completion of the
investigation described in subdivision (o), 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.
(9) Any other relevant information that has come to the attention
of the product affecting
(E) Any other information that affects
the content and or accuracy of
the provider directory. directory or
directories.
(2) Upon confirmation of any of the following, the insurer shall
delete a provider from the directory or directories when:
(A) A provider has retired or otherwise has ceased to practice.
(B) A provider or provider group is no longer under contract with
the insurer for any reason.
(C) The contracting provider group has informed the insurer that
the provider is no longer associated with the provider group and is
no longer under contract with the insurer.
(f) The 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. This information shall be disclosed
prominently in the directory or directories and on the insurer's
Internet Web site.
(g) The provider directory or directories 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.
services in accordance with Section 10133.8.
(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 each affiliated
medical groups provider group currently
under contract with the insurer through which the provider sees
enrollees.
(8) A listing for each of the following providers,
facilities, and services providers that are
under contract with the insurer:
(A) For physicians and surgeons, the medical
provider 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, as defined in Section
10144.51, 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 or directories 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,
10133.8 of the Ins urance Code, if
any, on the provider's staff. For purposes of this section,
"qualified interpreter" means that the interpreter meets the
proficiency standards established pursuant to subparagraph (H) of
paragraph (2) of subdivision (c) of Section 1300.67.04 of Title 28 of
the California Code of Regulations.
(11) Identification of providers who no longer accept new patients
for one or more some or all of the
insurer's products or for all of the insurer's
products.
(12) Network The 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
directory or 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 each affiliated
medical group, independent practice association,
provider group or specialty insurer practice group
currently under contract with the insurer through which the provider
sees insureds.
(8) The names of any each allied
health care professionals professional
to the extent there is a direct contract for those services covered
through the a contract with the
insurer.
(9) Non-English The 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 10133.8 of the Insurance
Code, if any, on the provider's staff. For purposes of this
section, "qualified interpreter" means that the interpreter
meets the proficiency standards established pursuant to
subparagraph (H) of paragraph (2) of subdivision (c) of Section
1300.67.04 of Title 28 of the California Code of Regulations.
(10) Identification of providers who no longer accept new patients
for some or all of the insurer's products.
(11) All other applicable information necessary to conduct a
provider search pursuant to paragraph (2) of subdivision (c).
(j) (1) The contract between the insurer and a provider shall
include a requirement that the provider inform the insurer within
five business days when either of the following occur:
(A) The provider is not accepting new patients.
(B) If the provider had previously not accepted new patients, the
provider is currently accepting new patients.
(2) If a provider who is not accepting new patients is contacted
by an insured or potential insured seeking to become a new patient,
the provider shall direct the insurer or potential insured to the
insurer for additional assistance in finding a provider and the
provider shall provide information to the individual on how to
contact the department to report any inaccuracy with the insurer's
directory or directories.
(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
(3) If an insured or potential
insured informs an insurer of a possible inaccuracy in the provider
directory or directories, the insurer shall immediately
promptly 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. to permit consistency in accordance
with subdivision (b) and paragraph (2) of subdivision (c) and
development of a multiplan directory by another entity. 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. No
more than two revisions of those standards shall be exempt from the
Administrative Procedure Act (Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code)
pursuant to this subdivision.
(2) In developing the standards under this subdivision, the
department shall seek input from interested parties throughout
the process of developing the standards 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.
Services and the State Department of Health Care Services.
(3) By July 31, 2017, or six 12
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) (1) An insurer shall take appropriate steps to ensure the
accuracy of the information concerning each provider listed in the
insurer's provider directory or directories in accordance with this
section, and shall, at least annually, review and update the entire
provider directory or directories for each product offered. Each
calendar year the insurer shall notify all contracted providers
described in subdivisions (h) and (i) as follows:
(A) For individual providers who are not affiliated with a
provider group described in subparagraph (A) or (B) of paragraph (8)
of subdivision (h) and providers described in subdivision (i), the
insurer shall notify each provider at least once every six months.
(B) For all other providers described in subdivision (h) who are
not subject to the requirements of subparagraph (A), the insurer
shall notify its contracted providers to ensure that all of the
providers are contacted by the insurer at least once annually.
(2) The notification shall include all of the following:
(A) The information the insurer has in its directory or
directories regarding the provider or provider group, including a
list of networks and products that include the contracted provider or
provider group.
(B) A statement that the failure to respond to the notification
may result in a delay of payment or reimbursement of a claim pursuant
to subdivision (p).
(C) Instructions on how the provider or provider group can update
the information in the provider directory or directories using the
online interface developed pursuant to subdivision (m).
(3) 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 confirm that the
information in the provider directory or directories is current and
accurate or update the information required to be in the directory or
directories pursuant to this section, including whether or not the
provider group is accepting new patients for each product.
(4) If the insurer does not receive an affirmative response and
confirmation from the provider that the information is current and
accurate or, as an alternative, updates any information required to
be in the directory or directories pursuant to this section, within
30 business days, the insurer shall take no more than 15 business
days to verify whether the provider's
information is correct or requires updates. The
insurer shall document the receipt and outcome of each attempt to
verify the information. If the insurer is unable to verify whether
the provider's information is correct or requires updates, the
insurer shall notify the provider 10 business days in advance of
removal that the provider will be removed from the directory or
directories. The provider shall be removed from the directory or
directories at the next required update of the provider directory or
directories after the 10-business day notice period. A provider shall
not be removed from the provider directory or directories if he or
she responds before the end of the 10-business day notice period.
(l)
(m) 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)
(1) The policies and procedures established
described under this
subdivision (l) 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)
(2) 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
or directories 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 generate an
acknowledgment of receipt from the health insurer.
Providers shall verify or submit changes to information required to
be in the directory or directories pursuant to this
section using the process required by the health
insurer.
(p)
(3) 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 site linking to a form where the
information can be reported directly to the insurer through its
Internet Web site.
(n) (1) This section does not prohibit an insurer from requiring
its provider groups or contracting specialized health insurers to
provide information to the insurer that is required by the insurer to
satisfy the requirements of this section for each of the providers
that contract with the provider group or contracting specialized
health insurer. This responsibility shall be specifically documented
in a written contract between the insurer and the provider group or
contracting specialized health insurer.
(2) If an insurer requires its contracting provider groups or
contracting specialized health insurers to provide the insurer with
information described in paragraph (1), the insurer shall continue to
retain responsibility for ensuring that the requirements of this
section are satisfied.
(q)
(o) (1) Whenever a health an
insurer receives a report indicating that information listed in
its provider directory or directories is inaccurate,
incomplete, confusing, or misleading, the insurer shall
immediately promptly investigate the
reported inaccuracy and, no later than 30 business days
following receipt of the communication,
report, either verify the accuracy of the information or update
the information in its provider directory or directories, as
applicable.
(2) When investigating a communication
report 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.
report.
(B) Document the receipt and outcome of each
communication. report. 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 or directories 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
required update, or the monthly
quarterly update immediately following that update.
sooner if required by federal law or regulations.
(r) Notwithstanding Section 10123.13,
(p) (1)
Commencing July 1, 2017, notwithstanding Sections 10123.13 and
10123.147, an insurer may delay payment or reimbursement
owed to a provider who has not responded
or provider group for any claims payment made to a provider or
provider group for up to one calendar month beginning on the first
day of the following month, if the provider or provider group fails
to respond 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
information as required under subdivision (l). The insurer shall not
delay payment unless it has attempted to verify the provider's or
provider group's information by all means of communication
available to the insurer, including in writing, electronically, or
by telephone. An insurer may seek to delay payment or reimbursement
owed to a provider or provider group only after the 10-business day
notice period described in paragraph (4) of subdivision (l) has
lapsed.
(2) An insurer shall notify the provider or provider group 10 days
before it seeks to delay payment or reimbursement to a provider or
provider group pursuant to this subdivision. If the insurer delays a
payment or reimbursement pursuant to this subdivision, the insurer
shall reimburse the full amount of any payment or reimbursement
subject to delay to the provider or provider group no later than
three business days following the date on which the insurer receives
the information required to be submitted by the provider or provider
group pursuant to subdivision (l).
(3) 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 or directories pursuant to
this section.
(s) (1) In
(q) In circumstances where the
department finds that an insured reasonably relied upon
materially 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. health insurance policy.
Prior to requiring reimbursement in these circumstances, the
department must shall conclude that the
services received by the insured were covered services under the
insured's insurance contract. health
insurance policy. 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.
(r) Whenever an insurer determines as a result of this section
that there has been a 10-percent change in the network for a product
in a region, the insurer shall file a statement with the
commissioner.
(t)
(s) 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)
(t) 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.
(u) For purposes of this section, "provider group" means a medical
group, independent practice association, or other similar group of
providers.
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.
