SB 137, as introduced, 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.
This bill would require health care service plans and insurers subject to regulation by the commissioner for services at alternative rates to make a provider directory available on its Internet Web site and to update the directory weekly. The bill would require the Department of Managed Health Care and the Department of Insurance to develop a standard provider directory template. 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 1367.27 is added to the Health and Safety
2Code, to read:
(a) (1) A health care service plan shall make
4available a provider directory or directories which shall provide
5information on contracting providers, including those that accept
6new patients. A provider directory shall not include information
7on a provider that does not have a current contract with the plan
8and that has not submitted a claim within the past three months.
9(2) If a plan uses different provider networks for different
10products, then the requirements of this section shall apply for each
11of the provider directories for each product. The plan shall provide
12information on different provider networks for different products
13in a manner that allows the public, enrollees, potential enrollees,
14the department, and other
state or federal agencies to identify which
15providers participate in which networks for which products.
16(3) The information regarding a provider directory or directories
17shall be available to the public and potential enrollees without any
18requirement that a member of the public or potential enrollee
19indicate intent to obtain coverage from the plan. The directory or
20directories shall be available to the public without requiring that
21an individual intends to purchase coverage or has coverage by
22providing a policy number or any other identifying information
23and without requiring an individual to create or access an account.
24(b) (1) The provider directory or directories shall be posted on
25the plan’s public Internet Web site through a clearly identifiable
26link or tab and in a manner that is accessible and searchable by
27the public, potential enrollees, enrollees
and providers. If another
28technology emerges that takes the place of Internet Web sites, the
29department shall direct the plan to make the information required
30under this section available on the subsequent technology. The
P3 1plan shall also make a hard copy of the directory or directories
2available upon request.
3(2) The plan shall update weekly the provider directory or
4directories posted pursuant to paragraph (1) with any change to
5contracting providers, including whether a contracting provider is
6accepting new patients.
7(3) The provider directory or directories shall include both an
8email address and a telephone number for members of the public
9to notify the plan if the provider directory information appears to
10be inaccurate.
11(4) By September 15, 2016, or no later than six months after
12the date that a standard
provider directory template is developed
13under subdivision (d), a plan shall use the template developed
14pursuant to subdivision (d) to display the provider directory or
15directories for each product offered by the plan.
16(c) The plan shall provide all of the following information for
17each of the provider directories used for a network:
18(1) The provider’s location and contact information.
19(2) The area of specialty, including board certification, if any.
20(3) (A) For physicians, the medical group, if any.
21(B) Psychologists, acupuncturists, optometrists, podiatrists,
22chiropractors, licensed clinical social workers, marriage and family
23therapists, professional clinical
counselors, and nurse midwives
24to the extent their services may be accessed and are covered
25through the contract with the plan.
26(4) Hospital admitting privileges, if any, for physicians and
27other health professionals contracted with the plan.
28(5) Non-English language, if any, spoken by a health
29professional as well as non-English language, if any, spoken by
30staff to the provider.
31(6) Access for persons with disabilities.
32(7) Whether a provider is accepting new patients with the
33product selected by the enrollee or potential enrollee.
34(d) (1) By March 15, 2016, the department and the Department
35of Insurance shall develop a standard provider directory template
36for
purposes of paragraph (3) of subdivision (b). The template
37shall include a glossary of terms used in the template. The template
38shall include information on how to contact the plan and the
39department.
P4 1(2) The template shall be sufficiently standardized to permit a
2single uniform directory that would allow a member of the public
3to determine whether a physician or other provider is available to
4an enrollee of the California Health Benefit Exchange as well as
5a beneficiary of the Medi-Cal program enrolled in a Medi-Cal
6managed care plan. The template shall also be sufficiently
7standardized to permit a single uniform directory that would allow
8a member of the public to determine whether a physician or other
9provider is available to an enrollee with group coverage as well
10as to a beneficiary of the Medi-Cal program enrolled in a Medi-Cal
11managed care plan or to an enrollee of the California Health Benefit
12Exchange.
13(3) The department and the Department of Insurance shall seek
14input from interested parties, including holding at least one public
15meeting. In developing the directory template, the department shall
16take into consideration any requirements for provider directories
17established by the federal Centers for Medicare and Medicaid
18Services.
19(e) (1) The plan shall provide the directory or directories to the
20department in a format and manner to be specified by the
21department.
22(2) The plan shall demonstrate no less than quarterly to the
23department that the information provided in the provider directory
24or directories is consistent with the information required under
25Sections 1367.03 and 1367.035, and other provisions of this
26chapter. The plan shall assure that other information reported to
27the department is
consistent with the information provided to
28enrollees, potential enrollees, and the department pursuant to this
29section.
30(3) The plan shall demonstrate to the department that enrollees
31or potential enrollees seeking a provider that is contracted with
32the network for a particular product can identify these providers
33and that the provider is accepting new patients. The plan shall
34ensure that the accuracy of the provider directory meets or exceeds
3597 percent.
36(4) The plan shall contact any provider which is listed in the
37provider directory and which has not submitted a claim within the
38prior quarter to determine whether the provider is accepting patients
39or referrals from the plan. If the provider does not respond within
P5 130 days, the plan shall remove the provider from the provider
2directory.
3(f) The plan shall provide
an electronic copy of, or upon request,
4one physical copy of the provider directory or directories to the
5following:
6(1) To the State Department of Health Care Services for
7Medi-Cal managed care networks.
8(2) To the California Health Benefit Exchange for the networks
9of the products offered through the California Health Benefit
10Exchange.
11(3) On request by CalPERS, to CalPERS.
12(4) On request by a group purchaser, provider directory or
13directories for the products available in the market segment of the
14group.
15(g) If a contracting provider, or the representative of a
16contracting provider, informs an enrollee or potential enrollee that
17the provider is not accepting new patients, the contract
between
18the plan and the provider shall require the provider to direct the
19enrollee or potential enrollee to the plan for additional assistance
20in finding a provider and also to the department to inform it of the
21possible inaccuracy in the provider directory. If an enrollee or
22potential enrollee informs a plan of a possible inaccuracy in the
23provider directory or directories, the plan shall undertake corrective
24action to assure the accuracy of the directory or directories.
25(h) This section does not prohibit a plan from requiring its
26contracting providers, contracting provider groups, or contracting
27specialized health care plans to satisfy the requirements of this
28section. If a plan delegates the responsibility of complying with
29this section to its contracting providers, contracting provider
30groups, or contracting specialized health care plans, the plan shall
31ensure that the requirements of this section are met.
32(i) Every health care service plan shall allow enrollees to request
33the information required by this section through their toll-free
34telephone number or in writing. On request of an enrollee or
35potential enrollee, the plan shall provide the information required
36under (a), (b), (c) and (g) in written form. The information provided
37in written form may be limited to the geographic region in which
38the enrollee or potential enrollee resides or intends to reside.
Section 10133.15 is added to the Insurance Code, to
40read:
(a) (1) A health insurer that contracts with providers
2for alternative rates of payment pursuant to Section 10133 shall
3make available a provider directory or directories which shall
4provide information on contracting providers, including those that
5accept new patients. A provider directory shall not include
6information on a provider that does not have a current contract
7with the insurer and that has not submitted a claim within the past
8three months.
9(2) If an insurer uses different provider networks for different
10products, then the requirements of this section shall apply for each
11of the provider directories for each product. The insurer shall
12provide information on different provider networks for different
13products in
a manner that allows the public, enrollees, potential
14enrollees, the department, and other state or federal agencies to
15identify which providers participate in which networks for which
16products.
17(3) The information regarding provider directory or directories
18shall be available to the public and potential enrollees without any
19requirement that a member of the public or potential enrollee
20indicate intent to obtain coverage from the insurer. The directory
21or directories shall be available to the public without requiring that
22an individual intends to purchase coverage or has coverage by
23providing a policy number or any other identifying information
24and without requiring an individual to create or access an account.
25(b) (1) The provider directory or directories shall be posted on
26the insurer’s public Internet Web site through a clearly identifiable
27link or tab and
in a manner that is accessible and searchable by
28the public, potential enrollees, enrollees, and providers. If another
29technology emerges that takes the place of Internet Web sites, the
30department shall direct the insurer to make the information required
31under this section available on the subsequent technology. The
32insurer shall also make a hard copy of the directory or directories
33available upon request.
34(2) The insurer shall update weekly the provider directory or
35directories posted pursuant to paragraph (1) with any change to
36contracting providers, including whether a contracting provider is
37accepting new patients.
38(3) The provider directory or directories shall include both an
39email address and a telephone number for members of the public
P7 1to notify the insurer if the provider directory information appears
2to be inaccurate.
3(4) By September 15, 2016, or no later than six months after
4the date that a standard provider directory template is developed
5under subdivision (d), an insurer shall use the template developed
6pursuant to subdivision (d) to display the provider directory or
7directories for each product offered by the insurer.
8(c) The insurer shall provide all of the following information
9for each of the provider directories used for a network:
10(1) The provider’s location and contact information.
11(2) The area of specialty, including board certification, if any.
12(3) (A) For physicians, the medical group, if any.
13(B) Psychologists, acupuncturists, optometrists, podiatrists,
14
chiropractors, licensed clinical social workers, marriage and family
15therapists, professional clinical counselors, and nurse midwives
16to the extent their services may be accessed and are covered
17through the contract with the insurer.
18(4) Hospital admitting privileges, if any, for physicians and
19other health professionals contracted with the insurer.
20(5) Non-English language, if any, spoken by a health
21professional as well as non-English language, if any, spoken by
22staff to the provider.
23(6) Access for persons with disabilities.
24(7) Whether a provider is accepting new patients with the
25product selected by the enrollee or potential enrollee.
26(d) (1) By March 15, 2016,
the Department of Managed Health
27Care and the department shall develop a standard provider directory
28template for purposes of paragraph (3) of subdivision (b). The
29template shall include a glossary of terms used in the template.
30The template shall include information on how to contact the plan
31and the department.
32(2) The template shall be sufficiently standardized to permit a
33single uniform directory that would allow a member of the public
34to determine whether a physician or other provider is available to
35an enrollee of the California Health Benefit Exchange as well as
36a beneficiary of the Medi-Cal program enrolled in a Medi-Cal
37managed care plan. The template shall also be sufficiently
38standardized to permit a single uniform directory that would allow
39a member of the public to determine whether a physician or other
40provider is available to an enrollee with group coverage as well
P8 1as to a beneficiary of the Medi-Cal program enrolled in a
Medi-Cal
2managed care plan or to an enrollee of the California Health Benefit
3Exchange.
4(3) The department and the Department of Managed Health
5Care shall seek input from interested parties, including holding at
6least one public meeting. In developing the directory template, the
7Department of Managed Health Care shall take into consideration
8any requirements for provider directories established by the federal
9Centers for Medicare and Medicaid Services.
10(e) (1) The insurer shall provide the directory or directories to
11the department in a format and manner to be specified by the
12department.
13(2) The insurer shall demonstrate no less than quarterly to the
14department that the information provided in the provider directory
15or directories is consistent with the information required under
16Section
10133.5 and other provisions of this part. The insurer shall
17assure that other information reported to the department is
18consistent with the information provided to enrollees, potential
19enrollees, and the department pursuant to this section.
20(3) The insurer shall demonstrate to the department that enrollees
21or potential enrollees seeking a provider that is contracted with
22the network for a particular product can identify these providers
23and that the provider is accepting new patients. The insurer shall
24ensure that the accuracy of the provider directory meets or exceeds
2597 percent.
26(4) The insurer shall contact any provider which is listed in the
27provider directory and which has not submitted a claim within the
28prior quarter to determine whether the provider is accepting patients
29or referrals from the plan. If the provider does not respond within
3030 days, the insurer shall remove
the provider from the provider
31directory.
32(f) The insurer shall provide an electronic copy of, or upon
33request, one physical copy of the provider directory or directories
34to the following:
35(1) To the State Department of Health Care Services for
36Medi-Cal managed care networks.
37(2) To the California Health Benefit Exchange for the networks
38of the products offered through the California Health Benefit
39Exchange.
40(3) On request by CalPERS, to CalPERS.
P9 1(4) On request by a group purchaser, provider directory or
2directories for the products available in the market segment of the
3group.
4(g) If a contracting provider, or the
representative of a
5contracting provider, informs an enrollee or potential enrollee that
6the provider is not accepting new patients, the contract between
7the insurer and the provider shall require the provider to direct the
8enrollee or potential enrollee to the insurer for additional assistance
9in finding a provider and also to the department to inform it of the
10possible inaccuracy in the provider directory. If an enrollee or
11potential enrollee informs an insurer of a possible inaccuracy in
12the provider directory or directories, the insurer shall undertake
13corrective action to assure the accuracy of the directory or
14directories.
15(h) This section does not prohibit an insurer from requiring its
16contracting providers, contracting provider groups, or contracting
17specialized health care plans to satisfy the requirements of this
18section. If an insurer delegates the responsibility of complying
19with this section to its contracting providers,
contracting provider
20groups, or contracting specialized health care plans, the insurer
21shall ensure that the requirements of this section are met.
22(i) Every health insurer shall allow enrollees to request the
23information required by this section through their toll-free
24telephone number or in writing. On request of an enrollee or
25potential enrollee, the insurer shall provide the information required
26under (a), (b), (c), and (g) in written form. The information
27provided in written form may be limited to the geographic region
28in which the enrollee or potential enrollee resides or intends to
29reside.
No reimbursement is required by this act pursuant to
31Section 6 of Article XIII B of the California Constitution because
32the only costs that may be incurred by a local agency or school
33district will be incurred because this act creates a new crime or
34infraction, eliminates a crime or infraction, or changes the penalty
35for a crime or infraction, within the meaning of Section 17556 of
36the Government Code, or changes the definition of a crime within
37the meaning of Section 6 of Article XIII B of the California
38Constitution.
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