BILL NUMBER: SB 137 AMENDED
BILL TEXT
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 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 provider directory 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 that shall provide information on
contracting providers, including those that accept new 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.
(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 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 seeking the directory information
demonstrate coverage with the plan, provide a policy number, provide
any other identifying information, or create or access an account.
(b) (1) The provider directory or directories shall be accessible
on the plan's public Internet Web site through a clearly identifiable
link or tab and in a manner that is accessible and searchable by the
public, potential enrollees, enrollees, and providers. The plan's
public Internet Web site shall allow for provider searches by name,
practice address, National Provider Identification
Identifier 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 in a timeframe that allows for implementation of the
technology, not to exceed six months. The plan shall also make a
paper copy of the directory or directories available upon request.
(2) The plan shall update the provider directory or directories,
at least weekly, pursuant to paragraph (1) with any change to
contracting providers, including all of the following:
(A) Whether a contracting provider is no longer accepting new
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) Whether 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) Whether 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 provider directory standards are developed under
subdivision (d), a plan shall use the developed standards pursuant to
subdivision (d) for each product offered by the plan.
(c) A full service health care service 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 Identification
Identifier number.
(4) California license number and type of license.
(5) The area of specialty, including board certification, if any.
(6) (A) For physicians, the medical group, if any.
(B) Nurse practitioners, physician assistants, psychologists,
acupuncturists, optometrists, podiatrists, chiropractors, licensed
clinical social workers, marriage and family therapists, professional
clinical counselors, 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.
(7) Hospital admitting privileges, if any, for physicians and
other health professionals contracted with the plan whose scope of
services for the plan include admitting patients and who have
admitting privileges at a hospital.
(8) Non-English language, if any, spoken by a health professional
as well as non-English language, if any, spoken by the provider's
staff.
(9) Whether a provider is accepting new patients with the product
selected by the enrollee or potential enrollee.
(10) Network tier to which the provider is assigned, if
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 enrollees are entitled to full and equal
access to covered services, including enrollees with disabilities as
required under the federal Americans with Disabilities Act
of 1990 and Section 504 of the Rehabilitation
Act. Act of 1973.
(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, practice location or locations, and
contact information.
(2) Type of practitioner.
(3) National Provider Identification
Identifier number.
(4) California license number and type of license.
(5) The area of specialty, including board certification, if any.
(6) If participating in a group practice, the name of the group
practice.
(7) The names of any allied health care professionals to the
extent 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 the provider's staff.
(9) Whether a provider is accepting new patients enrolled in the
product that the directory applies to.
(10) A disclosure that enrollees are entitled to full and equal
access to covered services, including enrollees with disabilities as
required under the federal Americans with Disabilities Act
of 1990 and Section 504 of the Rehabilitation
Act. Act of 1973.
(e) (1) By March 15, 2016, the department and the Department of
Insurance shall develop uniform provider directory
standards for purposes of paragraph (3) of subdivision (b).
subdivision (b) which would allow directories to be
aggregated and searchable to determine the plan a physician or other
provider is available through.
(2) The standards shall be 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, a beneficiary of
the Medi-Cal program enrolled in a Medi-Cal managed care plan, as
well as to an enrollee with group coverage.
(3)
(2) The department and the Department of Insurance
shall seek input from interested parties, including holding at least
one public meeting. In developing the directory standards, the
department shall take into consideration any requirements for
provider directories established by the federal Centers for Medicare
and Medicaid Services.
(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 ensure that other
information reported to the department is consistent with the
information provided to enrollees, potential enrollees, and the
department pursuant to this section.
(3) The plan shall demonstrate to the department that enrollees or
potential enrollees seeking a provider that is contracted with the
network for a particular product can identify these providers and
that the provider is accepting new patients. The plan shall ensure
that the accuracy of the provider directory meets or exceeds 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
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, 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.
(g) The plan shall 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 plans.
(2) To the California Health Benefit Exchange for the networks of
the products offered through the California Health Benefit Exchange,
as required by contract.
(3) On request by the Public Employees' Retirement System, to the
Public Employees' Retirement System.
(4) The department and the Department of Insurance.
(5) On request by a group purchaser, provider directory or
directories for the products available in the market segment of the
group.
(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 inform the plan
that the provider is not accepting new patients and direct the
enrollee or potential enrollee to the plan for additional assistance
in finding a provider and also to the department to inform it of the
possible inaccuracy in the provider directory. If an enrollee or
potential enrollee informs a plan of a possible inaccuracy in the
provider directory or directories, the plan shall undertake immediate
corrective action to ensure the accuracy of the directory or
directories.
(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.
(k) Every health care service plan shall allow enrollees to
request the information required by this section through their
toll-free telephone number, electronically, or in writing. On request
of an enrollee or potential enrollee, the plan shall provide the
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. 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 that shall provide
information on contracting providers, including those that accept new
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.
(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, insureds, potential insureds, the
department, and other state or federal agencies can easily identify
which providers participate in which networks for which products. An
insurer shall use the same consistent 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
products in order to permit the department and other state or
federal agencies to construct multiplan directories.
(3) The provider directory or directories shall be available on
the insurer's Internet Web site to the public and potential insureds
without any requirement that a member of the public or potential
insureds indicate intent to obtain coverage from the insurer. The
directory or directories shall be available to the public without
requiring that an individual seeking the directory information
demonstrate coverage with the insurer, provide a policy
number, provide any other identifying information, or create or
access an account.
(b) (1) The provider directory or directories shall be accessible
on the insurer's public Internet Web site through a clearly
identifiable link or tab and in a manner that is accessible and
searchable by the public, potential insureds, insureds, and
providers. The insurer's public Internet Web site shall allow for
provider searches by name, practice address, National Provider
Index Identifier number, 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 in a
timeframe that allows for implementation of the technology, not to
exceed six months. The insurer shall also make a paper copy of the
directory or directories available upon request.
(2) The insurer shall update the provider directory or
directories, at least weekly, posted pursuant to paragraph (1) with
any change to contracting providers, including all of the following:
(A) Whether a contracting provider has notified the insurer that
the provider no longer intends to participate as a contracting
provider, is no longer accepting new patients, that the provider
moved or relocated from the contracted service area of the product,
or has retired or otherwise ceased to practice.
(B) Whether 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) Whether the insurer identified a change based on an insured
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 product 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 provider directory standards are developed under
subdivision (d), an insurer shall use the developed standards
pursuant to subdivision (d) for each product offered by the insurer.
(c) The 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 Identification
Identifier number.
(4) California license number and type of license.
(5) The area of specialty, including board certification, if any.
(6) (A) For physicians, the medical group, if any.
(B) Nurse practitioners, physician assistants, psychologists,
acupuncturists, optometrists, podiatrists, chiropractors, licensed
clinical social workers, marriage and family therapists, professional
clinical counselors, 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 insurer, the name of the
provider, and the name of the federally qualified health center or
clinic.
(7) Hospital admitting privileges, if any, for physicians and
other health professionals contracted with the insurer whose scope of
services for the product include admitting patients and who have
admitting privileges at a hospital.
(8) Non-English language, if any, spoken by a health professional
as well as non-English language, if any, spoken by the provider's
staff.
(9) Whether a provider is accepting new patients with the product
selected by the insured or potential insured.
(10) Network tier that the provider is assigned to, if applicable.
"Tiered provider network" means a network of participating providers
that has been divided into subgroupings differentiated by the
insurer according to insured cost-sharing levels or quality scores.
Nothing in this section shall be construed to require the use of
network tiers other than 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 federal Americans with Disabilities Act
of 1990 and Section 504 of the Rehabilitation
Act. Act of 1973.
(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, practice location or locations, and
contact information.
(2) Type of practitioner.
(3) National Provider Identification
Identifier number.
(4) California license number and type of license.
(5) The area of specialty, including board certification, if any.
(6) If participating in a group practice, the name of the group
practice.
(7) The names of any allied health care professionals to the
extent their services are covered through the contract with the
insurer.
(8) Non-English language, if any, spoken by a health professional
as well as non-English language, if any, spoken by the provider's
staff.
(9) Whether a provider is accepting new patients enrolled in the
product that the directory applies to.
(10) A disclosure that insureds are entitled to full and equal
access to covered services, including insureds with disabilities as
required under the federal Americans with Disabilities Act
of 1990 and Section 504 of the Rehabilitation
Act. Act of 1973.
(e) (1) By March 15, 2016, the Department of Managed Health Care
and the department shall develop a uniform
provider directory standards for purposes of paragraph
(3) of subdivision (b). subdivision (b) which would
allow directories to be aggregated and searchable to determine the
plan a physician or other provider is available through.
(2) The standards shall be 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
insured of the California Health Benefit Exchange, a beneficiary of
the Medi-Cal program enrolled in a Medi-Cal managed care plan, as
well as to an insured with group coverage.
(3)
(2) The department and the Department of Managed Health
Care shall seek input from interested parties, including holding at
least one public meeting. In developing the directory standards, the
department and 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.
(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 ensure that other information
reported to the department is consistent with the information
provided to insureds, potential insureds, and the department pursuant
to this section.
(3) The insurer shall demonstrate to the department that insureds
or potential insureds seeking a provider that is contracted with the
network for a particular product can identify these providers and
that the provider is accepting new patients. The insurer shall ensure
that the accuracy of the provider directory meets or exceeds 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
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 insurer, if claims are paid
by the insurer. If the provider does not respond within 30 days, the
insurer shall remove the provider from the provider directory. 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.
(g) The insurer shall 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 plans.
(2) To the California Health Benefit Exchange for the networks of
the products offered through the California Health Benefit Exchange,
as required by contract.
(3) On request by the Public Employees' Retirement System, to the
Public Employees' Retirement System.
(4) The department and the Department of Managed Health Care.
(5) On request by a group purchaser, provider directory or
directories for the products available in the market segment of the
group.
(h) If a contracting provider, or the representative of a
contracting provider, informs an insured or potential insured that
the provider is not accepting new patients, the contract between the
insurer and the provider shall require the provider to inform the
insurer that the provider is not accepting new patients and direct
the insured or potential insured to the insurer for additional
assistance in finding a provider and also to the department to inform
it of the possible inaccuracy in the provider directory. If an
insured or potential insured informs an insurer of a possible
inaccuracy in the provider directory or directories, the insurer
shall undertake immediate corrective action to ensure the accuracy of
the directory or directories.
(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.
(k) Every health insurer shall allow insureds to request the
information required by this section through their toll-free
telephone number, electronically, or in writing. On request of an
insured or potential insured, the insurer shall provide the
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 insured or potential insured
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.