BILL NUMBER: SB 137 AMENDED
BILL TEXT
AMENDED IN SENATE MARCH 26, 2015
INTRODUCED BY Senator Hernandez
JANUARY 26, 2015
An act to add Section 1367.27 to 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 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 . standards. 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 1367.27 is added to the Health and Safety Code,
to read:
1367.27. (a) (1) A health care service plan shall make available
a provider directory or directories which
that shall provide information on contracting providers,
including those that accept new patients.
patients, pursuant to the requirements of this section and Section
1367.26. A provider directory shall not include information on
a provider that does not have a current contract with the
plan and that has not submitted a claim within the past three months.
plan.
(2) If a plan uses different provider networks for different
products, then the requirements of this section shall apply for each
of the provider directories for each product. The plan shall provide
information on different provider networks for different products in
a manner that allows the public, enrollees, potential enrollees, the
department, and other state or federal agencies to identify which
providers participate in which networks for which products.
(2) A 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
which providers participate in which networks for which products. A
health plan shall use the same consistent 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 classification shall be consistent across
plans in order to permit the department and other state or federal
agencies to construct multiplan directories.
(3) The information regarding a provider
directory or directories shall be available on the plan's
Internet Web site to the public and potential enrollees without
any requirement that a member of the public or potential enrollee
indicate intent to obtain coverage from the plan. The directory or
directories shall be available to the public without requiring that
an individual intends to purchase coverage or has coverage
by providing seeking the directory information
demonstrate coverage with the plan, provide a policy
number or number, provide any other identifying
information and without requiring an individual to
information, or create or access an account.
(b) (1) The provider directory or directories shall be
posted 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 the public, potential enrollees,
enrollees enrollees, and providers.
The plan's public Internet Web site shall allow for provider
searches by name, practice address, National Provider Identification
number, California license, facility or identification number,
product, tier, provider language, medical group, or independent
practice association, hospital, or clinic, as appropriate. If
another technology emerges that takes the place of Internet Web
sites, the department shall direct the plan to make the information
required under this section available on the subsequent
technology. technology in a timeframe that allows for
implementation of the technology, not to exceed six months. The
plan shall also make a hard paper copy
of the directory or directories available upon request.
(2) The plan shall update weekly the provider
directory or directories posted directories,
at least weekly, pursuant to paragraph (1) with any change to
contracting providers, including whether all
of the following:
(A) Instances where a contracting
provider is no longer accepting new patients.
patients, or that the provider moved or relocated from
the contracted service area of the plan, or has retired or has
otherwise ceased to practice.
(B) Instances where the contracting provider group, if any, has
identified that the provider is no longer associated with the group
or is no longer accepting new patients.
(C) Instances where the plan identified a change based on an
enrollee complaint that a provider was not accepting new patients or
was otherwise not available.
(D) Any other relevant information that has come to the attention
of the plan affecting the content of the provider directory.
(3) 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.
(4) By September 15, 2016, or no later than six months after the
date that a standard provider directory
template is standards are developed under
subdivision (d), a plan shall use the template
developed standards pursuant to subdivision (d)
to display the provider directory or directories for each
product offered by the plan.
(c) The A full service health care service
plan shall provide include all
of the following information for each of the provider
directories used for a network: in the provider
directory or directories:
(1) The provider's location name, location
(s), and contact information.
(2) Type of practitioner.
(3) National Provider Identification number.
(4) California license number and type of license.
(2)
(5) The area of specialty, including board
certification, if any.
(3)
(6) (A) For physicians, the medical group, if any.
(B) Psychologists, Nurse
practitioners, physician assistants, 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.
(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.
(4)
(7) Hospital admitting privileges, if any, for
physicians and other health professionals contracted with the
plan. plan whose scope of services for the
plan include admitting patients and who have admitting privileges at
a hospital.
(5)
(8) Non-English language, if any, spoken by a health
professional as well as non-English language, if any, spoken by staff
to the provider.
(6) Access for persons with disabilities.
(7) Whether a provider is accepting new patients with the product
selected by the enrollee or potential enrollee.
(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 assigne d, if applicable. "Tiered provider network"
means a network of participating providers that has been divided into
subgroupings differentiated by the health plan according to enrollee
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 enrolles are entitled to full and equal
access to covered services, including enrollees with disabilities as
required under the Americans with Disabilities Act and Section 504 of
the Rehabilitation Act.
(12) All other information necessary to conduct a search pursuant
to subdivision (b).
(d) A specialized health care service 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, location, and contact information.
(2) Type of Practitioner.
(3) National Provider Identification 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 their services are covered through the contract with the plan.
(8) Non-English language, if any, spoken by a health provider as
well as non-English language, if any, spoken by 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 Americans with Disabilities Act and Section 504 of
the Rehabilitation Act.
(d)
(e) (1) By March 15, 2016, the department and the
Department of Insurance shall develop a standard
provider directory template standards
for purposes of paragraph (3) of subdivision (b). The
template shall include a glossary of terms used in the template. The
template shall include information on how to contact the plan and the
department.
(2) The template standards shall be
sufficiently standardized sufficient to
permit a single uniform electronic directory that would
allow a member of the public to determine whether a physician or
other provider is available to an enrollee of the California Health
Benefit Exchange as well as a beneficiary of the Medi-Cal program
enrolled in a Medi-Cal managed care plan. The template shall
also be sufficiently standardized standards shall be
sufficient to permit a single uniform directory that would
allow a member of the public to determine whether a physician or
other provider is available to an enrollee with group coverage as
well as to a beneficiary of the Medi-Cal program enrolled in a
Medi-Cal managed care plan or to an enrollee of the California Health
Benefit Exchange.
(3) The department and the Department of Insurance shall seek
input from interested parties, including holding at least one public
meeting. In developing the directory template, the department shall
take into consideration any requirements for provider directories
established by the federal Centers for Medicare and Medicaid
Services.
(e)
(f) (1) The plan shall provide the 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 assure 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 97
percent.
(4) The plan shall contact any provider which is listed in the
provider directory and which has not submitted a claim within the
prior quarter past three months for primary
care providers, or six months for specialty care providers, to
determine whether the provider is accepting patients or referrals
from the plan. 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 three months for
primary care providers, or six 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. This requirement does not apply to claims or
encounter data from new primary care providers in the first three
months, or new specialty care providers in the first six months, of
the contract.
(f)
(g) The plan shall provide make
available an electronic copy of, or upon request, one physical
copy of the provider directory or directories to the following:
(1) To the State Department of Health Care Services for Medi-Cal
managed care networks. plans.
(2) To the California Health Benefit Exchange for the networks of
the products offered through the California Health Benefit
Exchange. Exchange, as required by contract.
(3) On request by CalPERS, to CalPERS. the
Public Employees' Retirement System, to the Public Employees'
Retirement System.
(4) The department and the Department of Insurance.
(4)
(5) On request by a group purchaser, provider directory
or directories for the products available in the market segment of
the group.
(g)
(h) 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 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 undertake
immediate corrective action to assure
ensure the accuracy of the directory or directories.
(h)
(i) 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.
(j) Every health care service plan shall ensure processes are in
place to allow providers to promptly verify or submit changes to
demographic information and participation status. 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
demographic information and participation status using this process
according to the terms of their contract with the contracted health
plan. Providers shall verify or submit changes to demographic
information and participation status using this process according to
the terms of their contract with the contracted health plan.
(i)
(k) Every health care service plan shall allow
enrollees to request the information required by this section through
their toll-free telephone number number,
electronically, or in writing. On request of an enrollee or
potential enrollee, the plan shall provide the information required
under subdivisions (a), (b), (c)
(c), and (g) in written form. The information provided in
written form may be limited to the geographic region in which the
enrollee or potential enrollee resides or intends to reside.
SEC. 2. Section 10133.15 is added to the Insurance Code, to read:
10133.15. (a) (1) A health insurer that contracts with providers
for alternative rates of payment pursuant to Section 10133 shall make
available a provider directory or directories which
that shall provide information on contracting
providers, including those that accept new patients.
patients pursuant to the requirements of this section
and Section 10133.1. A provider directory shall not include
information on a provider that does not have a current contract with
the insurer and that has not submitted a claim within the
past three months. insurer.
(2) If an insurer uses different provider networks for different
products, then the requirements of this section shall apply for each
of the provider directories for each product. The insurer shall
provide information on different provider networks for different
products in a manner that allows the public, enrollees, potential
enrollees, the department, and other state or federal agencies to
identify which providers participate in which networks for which
products.
(2) An insurer 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 which providers participate in
which networks for which products. An insurer shall use the
same consistent 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 classification shall be consistent across plans in order to
permit the department and other state or federal agencies to
construct multiplan directories.
(3) The information regarding provider
directory or directories shall be available on the insurer's
Internet Web site to the public and potential enrollees without
any requirement that a member of the public or potential enrollee
indicate intent to obtain coverage from the insurer. The directory or
directories shall be available to the public without requiring that
an individual intends to purchase coverage or has coverage
by providing seeking the directory information
demonstrate coverage with insurer, provide a policy
number or number, provide any other identifying
information and without requiring an individual to
information, or create or access an account.
(b) (1) The provider directory or directories shall be
posted 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 the public, potential
enrollees, enrollees, and providers. The insurer's public
Internet Web site shall allow for provider searches by name, practice
address, National Provider Index num ber, California
license number, facility or identification number, product, tier,
provider language, medical group, or independent practice
association, hospital, or clinic, as appropriate. If another
technology emerges that takes the place of Internet Web sites, the
department shall direct the insurer to make the information required
under this section available on the subsequent technology.
technology in a timeframe that allows for
implementation of the technology, not to exceed six months. The
insurer shall also make a hard paper
copy of the directory or directories available upon request.
(2) The insurer shall update weekly the
provider directory or directories
directories, at least weekly, posted pursuant to paragraph (1)
with any change to contracting providers, including whether
all of the following:
(A) Instances where a contracting
provider is has notified the insurer that
the provider no longer intents to participate as a contracting
provider, is no longer accepting new patients.
patients, that the provider moved or relocated from
the contracted service area of the plan, or has retired or otherwise
ceased to practice.
(B) Instances where the contracting provider group, if any, has
identified that the provider is no longer associated with the group
or is no longer accepting new patients.
(C) Instances where the plan identified a change based on an
enrollee complaint that a provider was not accepting new patients or
was otherwise not available.
(D) Any other relevant information that has come to the attention
of the plan affecting the content of the provider directory.
(3) 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.
(4) By September 15, 2016, or no later than six months after the
date that a standard provider directory
template is standards are developed under
subdivision (d), an insurer shall use the template
developed standards pursuant to subdivision (d)
to display the provider directory or directories for each
product offered by the insurer.
(c) The insurer shall provide include
all of the following information for each of the
provider directories used for a network: in the
provider directory or directories:
(1) The provider's location name,
location, and contact information.
(2) Type of practitioner.
(3) National Provider Identification number.
(4) California license number and type of license.
(2)
(5) The area of specialty, including board
certification, if any.
(3)
(6) (A) For physicians, the medical group, if any.
(B) Psychologists, Nurse practitioners,
physician assistants, 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 insurer.
(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.
(4)
(7) Hospital admitting privileges, if any, for
physicians and other health professionals contracted with the
insurer. insurer whose scope of services for
the plan include admitting patients and who have admitting privileges
at a hospital.
(5)
(8) Non-English language, if any, spoken by a health
professional as well as non-English language, if any, spoken by staff
to the provider.
(6) Access for persons with disabilities.
(7) Whether a provider is accepting new patients with the product
selected by the enrollee or potential enrollee.
(9) Whether a provider is accepting new patients with the product
selected by the enrollee or potential enrollee.
(10) Network tier that the provider is assigned to, if applicable.
"Tiered provider network" means a network of participating providers
that has been divided into subgroupings differentiated by the
insurer according to enrollee cost-sharing levels or quality scores.
Nothing in this section shall be construed to require the use of
network tiers other than contracting 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 Americans with Disabilities Act and Section 504 of
the Rehabilitation Act.
(12) All other information necessary to conduct a search pursuant
to subdivision (b).
(d) A specialized 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, location(s), and contact information.
(2) Type of practitioner.
(3) National Provider Identification 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 their services are covered through the contract with the plan.
(8) Non-English language, if any, spoken by a health professional
as well as non-English language, if any, spoken by 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
Americans with Disabilities Act and Section 504 of the Rehabilitation
Act.
(d)
(e) (1) By March 15, 2016, the Department of Managed
Health Care and the department shall develop a standard
provider directory template
standards for purposes of paragraph (3) of subdivision (b).
The template shall include a glossary of terms used in the
template. The template shall include information on how to contact
the plan and the department.
(2) The template standards shall be
sufficiently standardized sufficient to
permit a single uniform electronic directory that would
allow a member of the public to determine whether a physician or
other provider is available to an enrollee of the California Health
Benefit Exchange as well as a beneficiary of the Medi-Cal program
enrolled in a Medi-Cal managed care plan. The template shall
also be sufficiently standardized standards shall be
sufficient to permit a single uniform directory that would
allow a member of the public to determine whether a physician or
other provider is available to an enrollee with group coverage as
well as to a beneficiary of the Medi-Cal program enrolled in a
Medi-Cal managed care plan or to an enrollee of the California Health
Benefit Exchange.
(3) 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 template, the Department
of Managed Health Care shall take into consideration any requirements
for provider directories established by the federal Centers for
Medicare and Medicaid Services.
(e)
(f) (1) The insurer shall provide the 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
assure 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 insurer 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 insurer shall
ensure that the accuracy of the provider directory meets or exceeds
97 percent.
(4) The insurer shall contact any provider which is listed in the
provider directory and which has not submitted a claim within the
prior quarter past three months for primary
care providers, or six months for specialty care providers, to
determine whether the provider is accepting patients or referrals
from the plan. plan, 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.
This requirement does not apply to claims or claim data from new
primary care providers in the first three months, or new specialty
care providers in the first six months, of the contract.
(f)
(g) The insurer shall provide
make available an electronic copy of, or upon request, one
physical copy of the provider directory or directories to the
following:
(1) To the State Department of Health Care Services for Medi-Cal
managed care networks. plans.
(2) To the California Health Benefit Exchange for the networks of
the products offered through the California Health Benefit
Exchange. Exchange, as required by contract.
(3) On request by CalPERS, to CalPERS. the
Public Employees' Retirement System, to the Public
Employees' Retirement System.
(4) The department and the Department of Managed Health Care.
(4)
(5) On request by a group purchaser, provider directory
or directories for the products available in the market segment of
the group.
(g)
(h) 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 insurer and the provider shall require the provider to direct
the enrollee or potential enrollee 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
enrollee or potential enrollee informs an insurer of a possible
inaccuracy in the provider directory or directories, the insurer
shall undertake immediate corrective action to
assure ensure the accuracy of the directory or
directories.
(h)
(i) 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.
(j) Every insurer shall ensure processes are in place to allow
providers to promptly verify or submit changes to demographic
information and participation status. 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 demographic information
and participation status using this process according to the terms of
their contract with the insurer.
(i)
(k) Every health insurer shall allow enrollees to
request the information required by this section through their
toll-free telephone number number,
electronically, or in writing. On request of an enrollee or
potential enrollee, the insurer shall provide the information
required under subdivisions (a), (b), (c), and (g) in
written form. The information provided in written form may be limited
to the geographic region in which the enrollee or potential enrollee
resides or intends to reside.
SEC. 3. 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.