Amended in Assembly July 2, 2015

Amended in Senate June 1, 2015

Amended in Senate April 21, 2015

Amended in Senate March 26, 2015

Senate Bill No. 137

Introduced by Senator Hernandez

January 26, 2015

An act to add begin delete Section end delete begin insert Sections end insert 1367.27 begin insert and 1367.28 end insert to the Health and Safety Code, and to add begin delete Section end delete begin insert Sections end insert 10133.15 begin insert and 10133.16 end insert 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.

begin insert

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.

end insert begin insert

Commencing February 1, 2016, this bill would require health care service plans, and insurers subject to regulation by the commissioner for services at alternative rates, to make an online provider directory available on its Internet Web site, as specified.

end insert begin delete

This

end delete

begin insert Commencing, March 15, 2016, the bill would require the Department of Managed Health Care and the Department of Insurance to jointly develop uniform provider directory standards. Commencing September 15, 2016, or no later than 6 months after the provider directory standards are developed, this end insert bill would require health care service begin delete plans end delete begin insert plans, plans with Medi-Cal managed care contracts, end insert and insurers subject to regulation by the commissioner for services at alternative rates to make begin delete a end delete begin insert an online end insert provider directory available on its Internet Web site and to update the directory weekly. begin delete The bill would require the Department of Managed Health Care and the Department of Insurance to develop provider directory standards. end delete 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)  begin delete (1) end delete begin delete   end delete begin delete A end delete begin insert Commencing February 1, 2016, a end insert health
care service plan shall make available begin delete a end delete begin insert an online end insert provider
directory or directories that begin delete shall end delete provide information on
contracting begin delete providers, end delete begin insert providers that provide health care services
to plan enrollees, end insert 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.

begin delete

(2)

end delete

begin insert (b) end insert  A plan shall provide the begin insert online end insert 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 begin insert naming,
numbering, or end insert 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 begin insert naming, numbering, or end insert classification shall be consistent
across plans in order to permit begin delete the department and other state or
federal agencies to construct end delete multiplan directories.

begin delete

(3)

end delete

begin insert (c) end insert  The begin insert online end insert provider directory or directories shall be available
on the plan’s Internet Web site to the begin delete public and potential enrollees end delete
begin insert public, potential enrollees, enrollees, and providers through a
clearly identifiable link or tab and in a manner that is accessible
and searchable end insert 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.

begin delete

(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 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)

end delete

begin insert (d) end insert  The plan shall update the begin insert online end insert provider directory or
directories, at least weekly, begin delete pursuant to paragraph (1) end delete with any
change to contracting providers, including all of the following:

begin delete

(A)

end delete

begin insert (1) end insert  Whether a contracting provider is no longer accepting new begin delete 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. end delete begin insert patients for that product, or whether the
contracting provider group has identified that a provider of the
group is no longer accepting new patients. end insert

begin insert

(2) Whether the provider moved or relocated from the contracted
service area of the plan, has retired, or has otherwise ceased to
practice, in which case the provider shall be deleted from the
directory.

end insert begin delete

(B)

end delete

begin insert (3) end insert  Whether the contracting provider group, if any, has begin delete identified end delete
begin insert informed the plan end insert that the provider is no longer associated with
the group begin delete or is no longer accepting new patients. end delete begin insert and is no longer
under contract with the plan, in which case the provider shall be
deleted from the directory. end insert

begin delete

(C) Whether the plan identified

end delete

begin insert (4) end insert begin insert   end insert begin insert When the plan identified end insert a change begin insert is necessary end insert based on an
enrollee complaint that a provider was not accepting new begin delete patients
or end delete begin insert patients, end insert was otherwise not begin delete available. end delete begin insert available, or whose
contact information was listed incorrectly. end insert

begin delete

(D)

end delete

begin insert (5) end insert  Any other relevant information that has come to the attention
of the plan affecting the content begin insert and accuracy end insert of the provider
directory.

begin delete

(3)

end delete

begin insert (e) end insert  The begin insert online end insert 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.

begin delete

(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 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 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 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 of 1973.

(e) (1) By March 15, 2016, the department and the Department
of Insurance shall develop uniform provider directory standards
for purposes of 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 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 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.

end delete begin insert

(f) The online provider directory shall include the following
disclosures informing enrollees that they are entitled to both of
the following:

end insert begin insert

(1) Language interpreter services, at no cost to the enrollee,
including how to obtain interpretation services.

end insert begin insert

(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.

end insert

begin insert

begin insert SEC. 2. end insert   

end insert

begin insert Section 1367.28 is added to the end insert begin insert Health and Safety
Code end insert begin insert , to read: end insert

begin insert

begin insert 1367.28. end insert   

(a) (1) By March 15, 2016, the department and the
Department of Insurance shall jointly develop uniform provider
directory standards consistent with this section. These standards
shall also require directories to be aggregated and searchable to
determine the plan with which a physician or other provider is
contracted.

(2) The department and the Department of Insurance shall seek
input from interested parties, including holding at least one public
meeting. In developing the directory standards, the department
shall take into consideration any requirements for provider
directories established by the federal Centers for Medicare and
Medicaid Services.

(3) By September 15, 2016, or no later than six months after
the date that provider directory standards are developed a plan
shall use the developed standards for each product offered by the
plan.

(4) The uniform provider directory standards shall require the
plan’s public Internet Web site to allow for provider searches by
name, practice address, National Provider Identifier number,
California license, facility or identification number, product, tier,
provider language, medical group, or independent practice
association, hospital, or clinic, as appropriate.

(b) A full service health care service plan and a specialized
mental health plan shall include all of the following information
in the online provider directory or directories:

(1) The provider’s name, practice location or locations, and
contact information.

(2) Type of practitioner.

(3) National Provider Identifier number.

(4) California license number and type of license.

(5) The area of specialty, including board certification, if any.

(6) (A) For physicians, the medical group, if any.

(B) Nurse practitioners, physician assistants, psychologists,
acupuncturists, optometrists, podiatrists, chiropractors, licensed
clinical social workers, marriage and family therapists,
professional clinical counselors, nurse midwives, and dentists to
the extent their services may be accessed and are covered through
the contract with the plan. The plan may specify in the online
provider directory or directories that authorization or referral
may be required to access some providers.

(C) For federally qualified health centers or primary care
clinics, the name of the federally qualified health center or clinic.

(D) For any provider described in subparagraph (A) or (B) who
is employed by a federally qualified health center or primary care
clinic, and to the extent their services may be accessed and are
covered through the contract with the plan, the name of the
provider, and the name of the federally qualified health center or
clinic.

(E) Pharmacies.

(F) Skilled nursing facilities.

(G) Urgent care clinics.

(7) Hospital affiliation or admitting privileges, if any, for
physicians and other health professionals contracted with the plan
whose scope of services for the plan include admitting patients
and who have admitting privileges at a contracted hospital.

(8) Non-English language, if any, spoken by a health care
provider or other medical professional as well as non-English
language spoken by a skilled medical interpreter, if any, on the
provider’s staff.

(9) Whether a provider is accepting new patients with the
product selected by the enrollee or potential enrollee.

(10) Network tier to which the provider is assigned, if the
participating provider has been divided into subgroupings
differentiated by the health plan according to enrollee cost-sharing
levels. Nothing in this section shall be construed to require the use
of network tiers other than contract and noncontracting tiers.

(11) A disclosure that enrollees are entitled to full and equal
access to covered services, including enrollees with disabilities
as required under the federal Americans with Disabilities Act of
1990 and Section 504 of the Rehabilitation Act of 1973.

(12) A disclosure that enrollees are entitled to language
interpreter services at no cost to the enrollee, including how to
obtain interpretation services.

(13) All other information necessary to conduct a search
pursuant to subparagraph (A) of paragraph (4) of subdivision (a).

(c) A vision, dental and other specialized health care service
plan, except for a specialized mental health plan, shall include all
of the following information for each of the online provider
directories used by the plan for its networks:

(1) The provider’s name, practice location or locations, and
contact information.

(2) Type of practitioner.

(3) National Provider Identifier number.

(4) California license number and type of license.

(5) The area of specialty, including board certification, if any.

(6) If participating in a group practice, the name of the group
practice.

(7) The names of any allied health care professionals to the
extent there is a direct contract for those services covered through
the contract with the plan.

(8) Non-English language, if any, spoken by a health care
provider or other medical professional as well as non-English
language spoken by a skilled medical interpreter, if any, on the
provider’s staff.

(9) Whether a provider is accepting new patients enrolled in
the product that the directory applies to.

(10) A disclosure that enrollees are entitled to full and equal
access to covered services, including enrollees with disabilities
as required under the federal Americans with Disabilities Act of
1990 and Section 504 of the Rehabilitation Act of 1973.

(11) A disclosure that enrollees are entitled to language
interpreter services at no cost to the enrollee, including how to
obtain interpretation services.

(d) (1) The plan shall provide the online directory or directories
to the department in a format and manner to be specified by the
department.

(2) The plan shall demonstrate no less than quarterly to the
department that the information provided in the provider directory
or directories is consistent with the information required under
Sections 1367.03 and 1367.035, and other provisions of this
chapter. The plan shall ensure that other information reported to
the department is consistent with the information provided to
enrollees, potential enrollees, and the department pursuant to this
section.

(3) The plan shall demonstrate to the department that enrollees
or potential enrollees seeking a provider that is contracted with
the network for a particular product can identify these providers
and that the provider is accepting new patients. The plan shall
ensure that the accuracy of the provider directory meets or exceeds
95 percent with regard to the participation of providers in the
network, the extent to which the provider is accepting new patients,
and if any non-English language is spoken by the provider or other
medical professionals, as well as non-English language spoken
by a skilled medical interpreter, if any, on the provider’s staff.

(4) The plan shall contact any provider which is listed in the
provider directory and which has not submitted a claim within the
past six months for primary care providers, or twelve months for
specialty care providers, to determine whether the provider is
accepting patients or referrals from the plan, if claims are paid
by the plan. If claims are not paid by the plan, the plan shall
contact any provider that is listed in the provider directory who
has not submitted encounter data within the past six months for
primary care providers, or 12 months without encounter data for
a specialty care provider. If the provider does not respond within
30 days, the plan shall remove the provider from the provider
directory. A plan is not required to terminate a provider who is
removed from the directory according to this paragraph. This
requirement does not apply to claims or encounter data from new
primary care providers in the first six months, or new specialty
care providers in the first 12 months, of the contract. This
paragraph shall not apply if a provider has affirmatively responded
under the requirements of subdivision (h) that the provider
information is accurate and the provider is continuing to
participate in the network.

(e) If a contracting provider, or the representative of a
contracting provider, informs an enrollee or potential enrollee
that the provider is not accepting new patients, the contract
between the plan and the provider shall require the provider to
inform the plan that the provider is not accepting new patients
and direct the enrollee or potential enrollee to the plan for
additional assistance in finding a provider and also to the
department to inform it of the possible inaccuracy in the provider
directory. If an enrollee or potential enrollee informs a plan of a
possible inaccuracy in the provider directory or directories, the
plan shall immediately investigate and undertake corrective action
within 30 business days to ensure the accuracy of the directory or
directories.

(f) This section does not prohibit a plan from requiring its
contracting providers, contracting provider groups, or contracting
specialized health care plans to satisfy the requirements of this
section. If a plan delegates the responsibility of complying with
this section to its contracting providers, contracting provider
groups, or contracting specialized health care plans, the plan shall
ensure that the requirements of this section are met.

(g) Every health care service plan shall ensure processes are
in place to allow providers to promptly verify or submit changes
to the information required to be in the directory pursuant to this
section. Those processes shall, at a minimum, include an online
interface for providers to submit verification or changes
electronically and shall allow providers to receive an
acknowledgment of receipt from the health care service plan.
Providers shall verify or submit changes to information required
to be in the directory pursuant to this section using the process
required by the health plan.

(h) (1) At least every six months the plan shall notify the
contracted provider or provider group of the information on the
provider or provider group contained in the directory including
a list of each product marketed by the plan for the network. The
plan shall include with this notification instructions as to how to
access and update the information using the online interface in
subdivision (g).

(2) The plan shall require an affirmative response from the
provider or provider group acknowledging that the notification
was received and attesting that the information in the provider
directory is current and accurate. The provider shall update the
information required to be in the directory pursuant to this section,
including whether or not the provider or provider group is
accepting new patients for each product.

(3) If the plan does not receive an affirmative response and
attestation from the provider within 30 business days, the provider
shall be removed from the directory.

(i) Every health care service plan shall allow enrollees to
request the information required by this section through their
toll-free telephone number, electronically, or in writing. On request
of an enrollee or potential enrollee, the plan shall provide the
provider directory in printed form. The information provided in
printed form may be limited to the geographic region in which the
enrollee or potential enrollee resides or intends to reside.

(j) Notwithstanding the provisions of Section 1371, a plan may
use reasonable compliance methods, such as delaying payment or
reimbursement to a provider who has not responded or removal
of the provider from other directories only until the plan receives
an affirmative response and attestation from the provider. A plan
may terminate a contract for a pattern or repeated failure of the
provider or provider group to alert the plan to a change in the
information required to be in the directory pursuant to this section.
A plan may not impose any compliance method pursuant to this
subdivision without first providing written notice to the provider.

(k) This section shall apply to plans with Medi-Cal managed
care contracts with the State Department of Health Care Services
pursuant to Chapter 7 (commencing with Section 14000) or
Chapter 8 (commencing with Section 14200) of the Welfare and
Institutions Code to the extent consistent with federal law and
guidance.

(l) A health plan that contracts with multiple employer welfare
agreements regulated pursuant to Article 4.7 (commencing with
Section 742.20) of Chapter 1 of Part 2 of Division 1 of the
Insurance Code shall meet the requirements of this section.

end insert

begin delete SEC. 2. end delete
begin insert SEC. 3. end insert   

Section 10133.15 is added to the Insurance Code, to
read:

10133.15.  

(a)  begin delete (1) end delete begin delete   end delete begin delete A end delete begin insert Commencing February 1, 2016, a end insert health
insurer that contracts with providers for alternative rates of payment
pursuant to Section 10133 shall make available begin delete a end delete begin insert an online end insert provider
directory or directories that begin delete shall end delete provide information on
contracting begin delete providers, end delete begin insert providers that provide health care services
to insureds, end insert 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.

begin delete

(2)

end delete

begin insert (b) end insert  An insurer shall provide the begin insert online end insert 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 begin insert naming,
numbering, or end insert 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 begin insert naming, numbering, or end insert classification shall be consistent
across products in order to permit begin delete the department and other state
or federal agencies to construct end delete multiplan directories.

begin delete

(3)

end delete

begin insert (c) end insert  The begin insert online end insert provider directory or directories shall be available
on the insurer’s Internet Web site to the begin delete public and potential
insureds end delete begin insert public, potential insureds, insureds, and providers through
a clearly identifiable link or tab and in a manner that is accessible
and searchable end insert 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.

begin delete

(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
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)

end delete

begin insert (d) end insert  The insurer shall update the begin insert online end insert provider directory or
directories, at least weekly, begin delete posted pursuant to paragraph (1) end delete with
any change to contracting providers, including all of the following:

begin delete

(A)

end delete

begin insert (1) end insert  Whether a contracting provider begin delete has notified the insurer that
the provider no longer intends to participate as a contracting
provider, end delete is no longer accepting new begin delete patients, that the provider
moved or relocated from the contracted service area of the product,
or has retired or otherwise ceased to practice. end delete begin insert patients for that
product, or whether the contracting provider group has identified
that a provider of the group is no longer accepting new patients. end insert

begin insert

(2) Whether the provider moved or relocated from the contracted
service area of the insurer, or has retired or has otherwise ceased
to practice, in which case the provider shall be deleted from the
directory.

end insert begin delete

(B)

end delete

begin insert (3) end insert  Whether the contracting provider group, if any, has begin delete identified end delete
begin insert informed the insurer end insert that the provider is no longer associated with
the group begin delete or is no longer accepting new patients. end delete begin insert and is no longer
under contract with the plan, in which case the provider shall be
deleted from the directory. end insert

begin delete

(C) Whether the insurer identified

end delete

begin insert (4) end insert begin insert   end insert begin insert When the plan identified end insert a change begin insert is necessary end insert based on an
insured complaint that a provider was not accepting new begin delete patients
or end delete begin insert patients, end insert was otherwise not begin delete available. end delete begin insert available, or whose
contact information was listed incorrectly. end insert

begin delete

(D)

end delete

begin insert (5) end insert  Any other relevant information that has come to the attention
of the product affecting the content begin insert and accuracy end insert of the provider
directory.

begin delete

(3)

end delete

begin insert (e) end insert  The begin insert online end insert 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.

begin delete

(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 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 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 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 of 1973.

(e) (1) By March 15, 2016, the Department of Managed Health
Care and the department shall develop uniform provider directory
standards for purposes of 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 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
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.

end delete begin insert

(f) The online provider directory shall include the following
disclosures informing insureds that they are entitled to both of the
following:

end insert begin insert

(1) Language interpreter services, at no cost to the insured,
including how to obtain interpretation services.

end insert begin insert

(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.

end insert

begin insert

begin insert SEC. 4. end insert   

end insert

begin insert Section 10133.16 is added to the end insert begin insert Insurance Code end insert begin insert , to
read: end insert

begin insert

begin insert 10133.16. end insert   

(a) (1) By March 15, 2016, the department and the
Department of Managed Health Care shall jointly develop uniform
provider directory standards consistent with this section. These
standards shall also require directories to be aggregated and
searchable to determine the insurer with which a physician or
other provider is contracted.

(2) The department and the Department of Managed Health
Care shall seek input from interested parties, including holding
at least one public meeting. In developing the directory standards,
the department shall take into consideration any requirements for
provider directories established by the federal Centers for
Medicare and Medicaid Services.

(3) By September 15, 2016, or no later than six months after
the date that provider directory standards are developed, an
insurer shall use the developed standards for each product offered
by the insurer.

(4) The uniform provider directory standards shall require the
insurer’s public Internet Web site to allow for provider searches
by name, practice address, National Provider Identifier number,
California license number, facility or identification number,
product, tier, provider language, medical group, or independent
practice association, hospital, or clinic, as appropriate.

(b) The insurer and a specialized mental health insurer shall
include all of the following information in the online provider
directory or directories:

(1) The provider’s name, practice location or locations, and
contact information.

(2) Type of practitioner.

(3) National Provider Identifier number.

(4) California license number and type of license.

(5) The area of specialty, including board certification, if any.

(6) (A) For physicians, the medical group, if any.

(B) Nurse practitioners, physician assistants, psychologists,
acupuncturists, optometrists, podiatrists, chiropractors, licensed
clinical social workers, marriage and family therapists,
professional clinical counselors, nurse midwives, and dentists to
the extent their services may be accessed and are covered through
the contract with the insurer. The insurer may specify in the
provider directory or directories that authorization or referral
may be required to access some providers.

(C) For federally qualified health centers or primary care
clinics, the name of the federally qualified health center or clinic.

(D) For any provider described in subparagraph (A) or (B) who
is employed by a federally qualified health center or primary care
clinic, and to the extent their services may be accessed and are
covered through the contract with the insurer, the name of the
provider, and the name of the federally qualified health center or
clinic.

(E) Pharmacies.

(F) Skilled nursing facilities.

(G) Urgent care clinics.

(7) Hospital affiliation or admitting privileges, if any, for
physicians and other health professionals contracted with the
insurer whose scope of services for the product include admitting
patients and who have admitting privileges at a contracted hospital.

(8) Non-English language, if any, spoken by a health care
provider or other medical professional as well as non-English
language spoken by a skilled medical interpreter, if any, on the
provider’s staff.

(9) Whether a provider is accepting new patients with the
product selected by the insured or potential insured.

(10) Network tier that the provider is assigned if the
participating provider has been divided into subgroupings
differentiated by the insurer according to insured cost-sharing
levels or quality scores. Nothing in this section shall be construed
to require the use of network tiers other than contract and
noncontracting tiers.

(11) A disclosure that insureds are entitled to full and equal
access to covered services, including insureds with disabilities as
required under the federal Americans with Disabilities Act of 1990
and Section 504 of the Rehabilitation Act of 1973.

(12) A disclosure that insureds are entitled to language
interpreter services at no cost to the insured, including how to
obtain interpretation services.

(13) All other information necessary to conduct a search
pursuant to subparagraph (A) of paragraph (4) of subdivision (a).

(c) A vision, dental, and other specialized insurer, except for a
specialized mental health insurer, shall include all of the following
information for each of the online provider directories used by the
insurer for its networks:

(1) The provider’s name, practice location or locations, and
contact information.

(2) Type of practitioner.

(3) National Provider Identifier number.

(4) California license number and type of license.

(5) The area of specialty, including board certification, if any.

(6) If participating in a group practice, the name of the group
practice.

(7) The names of any allied health care professionals to the
extent there is a direct contract for those services covered through
the contract with the insurer.

(8) Non-English language, if any, spoken by a health care
provider or other medical professional as well as non-English
language spoken by a skilled medical interpreter, if any, on the
provider’s staff.

(9) Whether a provider is accepting new patients enrolled in
the product that the directory applies to.

(10) A disclosure that insureds are entitled to full and equal
access to covered services, including insureds with disabilities as
required under the federal Americans with Disabilities Act of 1990
and Section 504 of the Rehabilitation Act of 1973.

(11) A disclosure that insureds are entitled to language
interpreter services at no cost to the insured, including how to
obtain interpretation services.

(d) (1) The insurer shall provide the online directory or
directories to the department in a format and manner to be
specified by the department.

(2) The insurer shall demonstrate no less than quarterly to the
department that the information provided in the provider directory
or directories is consistent with the information required under
Section 10133.5 and other provisions of this part. The insurer shall
ensure that other information reported to the department is
consistent with the information provided to insureds, potential
insureds, and the department pursuant to this section.

(3) The insurer shall demonstrate to the department that
insureds or potential insureds seeking a provider that is contracted
with the network for a particular product can identify these
providers and that the provider is accepting new patients. The
insurer shall ensure that the accuracy of the provider directory
meets or exceeds 95 percent with regard to the participation of
providers in the network, the extent to which the provider is
accepting new patients, as well as non-English language spoken
by a skilled medical interpreter, if any, on the provider’s staff.

(4) The insurer shall contact any provider which is listed in the
provider directory and which has not submitted a claim within the
past six months for primary care providers, or 12 months for
specialty care providers, to determine whether the provider is
accepting patients or referrals from the insurer, if claims are paid
by the insurer. If the provider does not respond within 30 days,
the insurer shall remove the provider from the provider directory.
An insurer is not required to terminate a provider who is removed
from the directory according to this paragraph. This requirement
does not apply to claims or claim data from new primary care
providers in the first six months, or new specialty care providers
in the first 12 months, of the contract. This paragraph shall not
apply if a provider has affirmatively responded under the
requirements of subdivision (h) that the provider information is
accurate and the provider is continuing to participate in the
network.

(e) If a contracting provider, or the representative of a
contracting provider, informs an insured or potential insured that
the provider is not accepting new patients, the contract between
the insurer and the provider shall require the provider to inform
the insurer that the provider is not accepting new patients and
direct the insured or potential insured to the insurer for additional
assistance in finding a provider and also to the department to
inform it of the possible inaccuracy in the provider directory. If
an insured or potential insured informs an insurer of a possible
inaccuracy in the provider directory or directories, the insurer
shall immediately investigate and undertake corrective action
within 30 business days to ensure the accuracy of the directory or
directories.

(f) This section does not prohibit an insurer from requiring its
contracting providers, contracting provider groups, or contracting
specialized health care plans to satisfy the requirements of this
section. If an insurer delegates the responsibility of complying
with this section to its contracting providers, contracting provider
groups, or contracting specialized health care plans, the insurer
shall ensure that the requirements of this section are met.

(g) Every insurer shall ensure processes are in place to allow
providers to promptly verify or submit changes to the information
required to be in the directory pursuant to this section. Those
processes shall, at a minimum, include an online interface for
providers to submit verification or changes electronically and
shall allow providers to receive an acknowledgment of receipt
from the health insurer. Providers shall verify or submit changes
to information required to be in the directory pursuant to this
section using the process required by the insurer.

(h) (1) At least once every six months the insurer shall notify
the contracted provider or provider group of the information on
the provider or provider group contained in the directory including
a list of each product marketed by the insurer for the network. The
insurer shall include with this notification, instructions as to how
to access and update the information using the online interface in
subdivision (g).

(2) The insurer shall require an affirmative response from the
provider or provider group acknowledging that the notification
was received and attesting that the information in the provider
directory is current and accurate. The provider shall update the
information required to be in the directory pursuant to this section,
including whether or not the provider or provider group is
accepting new patients for each product.

(3) If the insurer does not receive an affirmative response and
attestation from the provider within 30 business days, the provider
shall be removed from the directory.

(i) Every health insurer shall allow insureds to request the
information required by this section through their toll-free
telephone number, electronically, or in writing. On request of an
insured or potential insured, the insurer shall provide the provider
directory in printed form. The information provided in printed
form may be limited to the geographic region in which the insured
or potential insured resides or intends to reside.

(j) Notwithstanding the provisions of Section 10123.13, an
insurer may use reasonable compliance methods, such as delaying
payment or reimbursement to a provider who has not responded
or removal of the provider from other directories only until the
plan receives an affirmative response and attestation from the
provider. An insurer may terminate a contract for a pattern or
repeated failure of the provider or provider group to alert the
insurer to a change in the information required to be in the
directory pursuant to this section. An insurer may not impose any
compliance method pursuant to this subdivision without first
providing written notice to the provider.

(k) An insurer that contracts with multiple employer welfare
agreements regulated pursuant to Article 4.7 (commencing with
Section 742.20) of Chapter 1 of Part 2 of Division 1 shall meet
the requirements of this section.

end insert

begin delete SEC. 3. end delete
begin insert SEC. 5. end insert   

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.