Amended in Assembly July 16, 2015

Amended in Assembly July 2, 2015

Amended in Senate June 1, 2015

Amended in Senate April 21, 2015

Amended in Senate March 26, 2015

Senate Bill No. 137

Introduced by Senator Hernandez

January 26, 2015

An act to add begin delete Sections end delete begin insert Section end insert 1367.27 begin delete and 1367.28 to end delete begin insert to, and repeal Section 1367.26 of, end insert the Health and Safety Code, and to add begin delete Sections end delete begin insert Section end insert 10133.15 begin delete and 10133.16 end delete 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.

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.

begin delete Commencing February 1, 2016, this end delete begin insert This end insert 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.

begin delete Commencing, March 15, 2016, the end delete begin insert This end insert bill would require the Department of Managed Health Care and the Department of Insurance to jointly develop uniform provider directory standards. begin delete Commencing September 15, 2016, or no later than 6 months after the provider directory standards are developed, this end delete begin insert The end insert bill would require health care service plans, plans with Medi-Cal managed care contracts, and insurers subject to regulation by the commissioner for services at alternative rates to make an online provider directory available on its Internet Web site and to update the directory begin delete weekly. end delete begin insert , as specified. The bill would require a health care service plan or insurer to reimburse an enrollee or insured for any amount beyond what the enrollee, or insured would have paid for in-network services, if the enrollee or insured reasonably relied on the provider directory, as specified. end insert 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:

begin insert

begin insert SECTION 1. end insert   

end insert

begin insert Section 1367.26 of the end insert begin insert Health and Safety Code end insert
begin insert is repealed. end insert

begin delete

1367.26.  

(a) A health care service plan shall provide, upon
request, a list of the following contracting providers, within the
enrollee’s or prospective enrollee’s general geographic area:

(1) Primary care providers.

(2) Medical groups.

(3) Independent practice associations.

(4) Hospitals.

(5) All other available contracting physicians and surgeons,
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.

(b) This list shall indicate which providers have notified the
plan that they have closed practices or are otherwise not accepting
new patients at that time.

(c) The list shall indicate that it is subject to change without
notice and shall provide a telephone number that enrollees can
contact to obtain information regarding a particular provider. This
information shall include whether or not that provider has indicated
that he or she is accepting new patients.

(d) A health care service plan shall provide this information in
written form to its enrollees or prospective enrollees upon request.
A plan may, with the permission of the enrollee, satisfy the
requirements of this section by directing the enrollee or prospective
enrollee to the plan’s provider listings on its Internet Web site.
Plans shall ensure that the information provided is updated at least
quarterly. A plan may satisfy this update requirement by providing
an insert or addendum to any existing provider listing. This
requirement shall not mandate a complete republishing of a plan’s
provider directory.

(e) Each plan shall make information available, upon request,
concerning a contracting provider’s professional degree, board
certifications, and any recognized subspeciality qualifications a
specialist may have.

(f) Nothing in this section shall prohibit a plan from requiring
its contracting providers, contracting provider groups, or
contracting specialized health care plans to satisfy these
requirements. 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 allow enrollees to request
the information required by this section through their toll-free
telephone number or in writing.

end delete

begin delete SECTION 1. end delete
begin insert SEC. 2. end insert   

Section 1367.27 is added to the Health and Safety
Code, to read:

1367.27.  

(a)  begin delete Commencing February 1, 2016, a end delete begin insert A end insert health care
service plan shall begin delete make available an online end delete begin insert publish and maintain
a end insert provider directory or directories begin delete that provide end delete begin insert with end insert information
on contracting providers that begin delete provide end delete begin insert deliver end insert health care services
to begin delete plan end delete begin insert the plan’s end insert enrollees, including those that accept new
begin delete patients, pursuant to the requirements of this section and Section
1367.26. end delete begin insert patients. end insert A provider directory shall not begin insert list or end insert include
information on a provider that begin delete does not have a current end delete begin insert is not
currently under end insert contract with the plan.

(b) A begin insert health care service end insert plan shall provide the begin delete online end delete 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 begin delete which providers participate in
which networks forwhich products. A health plan shall use the
same consistent naming, numbering, or 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 naming, numbering, or
classification shall be consistent across plans in order to permit
multiplan directories. end delete begin insert the networks and plan products in which a
provider participates. By July 31, 2017, or six months after the
date provider directory standards are developed under this section,
a health care service plan shall use the naming, numbering, or
classification method developed by the department pursuant to
subdivision (k). end insert

(c)  begin delete The end delete begin insert (1) end insert begin insert   end insert begin insert An end insert online provider directory or directories shall be
available on the plan’s Internet Web site to the public, potential
enrollees, enrollees, and providers begin delete through a clearly identifiable
link or tab and in a manner that is accessible and searchable without
any requirement that a member of the public or potential enrollee
indicate intent to obtain coverage from the plan. end delete begin insert without any
restrictions or limitations. end insert The directory or directories shall be
begin delete available to the public without requiring end delete begin insert accessible without any
requirement end insert that an individual seeking the directory information
demonstrate coverage with the plan, begin insert indicate interest in obtaining
coverage with the plan, end insert provide a begin insert member identification or end insert policy
number, provide any other identifying information, or create or
access an account.

begin insert

(2) The online 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 enrollees, potential enrollees, the public, and
providers. The plan’s public Internet Web site shall allow provider
searches by name, practice address, distance from specified
address, California license number, National Provider Identifier
number, admitting privileges to an identified hospital, product,
tier, provider language, medical group or independent practice
association, hospital name, facility name, or clinic name, as
appropriate.

end insert begin insert

(d) (1) A health care service plan shall allow enrollees,
potential enrollees, and members of the public to request a printed
copy of the provider directory or directories by contacting the plan
through the plan’s toll-free telephone number, electronically, or
in writing. A printed copy of the provider directory or directories
shall include the information required in subdivisions (h) and (i).
The printed copy of the provider directory or directories shall be
provided to the enrollee by mail no later than 15 business days
following the date of the request and may be limited to the
geographic region in which the enrollee resides or works or intends
to reside or work.

end insert begin insert

(2) A health care service plan shall update its printed provider
directory or directories at least quarterly, or more frequently, if
required by federal law.

end insert begin delete

(d)

end delete

begin insert (e) end insert  The plan shall update the online provider directory or
directories, at least begin delete weekly, with any change to contracting
providers, including all of the following: end delete begin insert weekly, or more
frequently, if required by federal law. Any change in information
concerning a listed contracting provider shall be included in the
updated version required by this subdivision. A change in
information includes, but is not limited to, any of the following: end insert

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

(2) Whether the provider begin delete moved or relocated from end delete begin insert relocated
out of end insert the contracted service area of the plan, has retired, or has
otherwise ceased to begin delete practice, in which case end delete begin insert practice. In all of these
cases, end insert the provider shall be deleted from the directory.

begin insert

(3) Whether the provider is no longer contracted with the plan
for any reason, in which case the provider shall be deleted from
the directory.

end insert begin insert

(4) Whether the contracted provider is no longer under contract
for a particular product.

end insert begin insert

(5) Whether the provider’s practice location or other
information required under subdivision (h) has changed.

end insert begin delete

(3)

end delete

begin insert (6) end insert  Whether the contracting begin delete provider group, end delete begin insert medical group,
independent practice association, or other group of providers, end insert if
any, has informed the plan that the provider is no longer associated
with the group and is no longer under contract with the plan, in
which case the provider shall be deleted from the directory.

begin insert

(7) Whether the contracting medical group, independent practice
association, or other group of providers has informed the plan
that the provider group is no longer under contract with the plan,
in which case any provider of the group that does not maintain an
independent contract with the plan shall be deleted from the
directory.

end insert begin delete

(4)

end delete

begin insert (8) end insert  When the plan identified a change is necessary based on an
enrollee complaint that a provider was not accepting new patients,
was otherwise not available, or whose contact information was
listed incorrectly.

begin delete

(5)

end delete

begin insert (9) end insert  Any other relevant information that has come to the attention
of the plan affecting the content and accuracy of the provider
directory.

begin delete

(e)

end delete

begin insert (f) end insert  The begin delete online end delete 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

(f)

end delete

begin insert (g) end insert  The begin delete online end delete provider directory shall include the following
disclosures informing enrollees that they are entitled to both of the
following:

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

(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.

begin insert

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

end insert begin insert

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

end insert begin insert

(2) Type of practitioner.

end insert begin insert

(3) National Provider Identifier number.

end insert begin insert

(4) California license number and type of license.

end insert begin insert

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

end insert begin insert

(6) The provider’s office email address, if available.

end insert begin insert

(7) The name of all affiliated medical groups currently under
contract with the plan through which the provider sees enrollees.

end insert begin insert

(8) A listing for each of the following providers, facilities, and
services that are under contract with the plan:

end insert begin insert

(A) For physicians and surgeons, the medical group, and
affiliation or admitting privileges, if any, at hospitals contracted
with the plan.

end insert begin insert

(B) Nurse practitioners, physician assistants, psychologists,
acupuncturists, optometrists, podiatrists, chiropractors, licensed
clinical social workers, marriage and family therapists,
professional clinical counselors, substance abuse counselors,
qualified autism service providers, nurse midwives, and dentists.

end insert begin insert

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

end insert begin insert

(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.

end insert begin insert

(E) Facilities, including, but not limited to, general acute care
hospitals, skilled nursing facilities, urgent care clinics, ambulatory
surgery centers, inpatient hospice, residential care facilities, and
inpatient rehabilitation facilities.

end insert begin insert

(F) Pharmacies, clinical laboratories, imaging centers, and
other facilities providing contracted health care services.

end insert begin insert

(9) The provider directory may note that authorization or
referral may be required to access some providers.

end insert begin insert

(10) Non-English language, if any, spoken by a health care
provider or other medical professional as well as non-English
language spoken by a qualified medical interpreter, in accordance
with Section 1367.04, if any, on the provider’s staff.

end insert begin insert

(11) Identification of providers who no longer accept new
patients for one or more of the plan’s products or for all of the
plan’s products.

end insert begin insert

(12) Network tier to which the provider is assigned, if the
provider is not in the lowest tier, as applicable. Nothing in this
section shall be construed to require the use of network tiers other
than contract and noncontracting tiers.

end insert begin insert

(13) All other information necessary to conduct a search
pursuant to paragraph (2) of subdivision (c).

end insert begin insert

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

end insert begin insert

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

end insert begin insert

(2) Type of practitioner.

end insert begin insert

(3) National Provider Identifier number.

end insert begin insert

(4) California license number and type of license, if applicable.

end insert begin insert

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

end insert begin insert

(6) The provider’s office email address, if available.

end insert begin insert

(7) The name of any affiliated medical group, independent
practice association, or specialty plan practice group currently
under contract with the plan through which the provider sees
enrollees.

end insert begin insert

(8) 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.

end insert begin insert

(9) Non-English language, if any, spoken by a health care
provider or other medical professional as well as non-English
language spoken by a qualified medical interpreter, in accordance
with Section 1367.04, if any, on the provider’s staff.

end insert begin insert

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

end insert begin insert

(k) (1) On or before December 31, 2016, the department shall
develop uniform provider directory standards for purposes of this
section. Those standards shall not be subject to the Administrative
Procedure Act (Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code), until
January 1, 2021.

end insert begin insert

(2) In developing the standards under this subdivision, the
department shall seek input from interested parties and shall hold
at least one public meeting. The department shall take into
consideration any requirements for provider directories established
by the federal Centers for Medicare and Medicaid Services.

end insert begin insert

(3) By July 31, 2017, or six months after the date provider
directory standards are developed under this subdivision,
whichever occurs later, a plan shall use the standards developed
by the department for each product offered by the plan.

end insert begin insert

(l) A plan shall establish policies and procedures with regard
to the regular updating of its provider directory or directories,
including the weekly, quarterly, and annual updates required
pursuant to this section, or more frequently, if required by federal
law or guidance.

end insert begin insert

(m) The policies and procedures established under this
subdivision shall be submitted by a plan annually to the department
for approval and in a format described by the department pursuant
to Section 1367.035.

end insert begin insert

(1) At a minimum, these policies and procedures shall include
all of the following:

end insert begin insert

(A) At least annually, the plan shall review and update the entire
provider directory or directories for each product offered.

end insert begin insert

(B) At least quarterly, the plan shall notify the contracted
provider or provider group, if applicable, of the information the
plan has in the directory or directories on the provider or provider
group contained in the directory, including a list of networks and
plan products that include the contracted provider or provider
group. The plan shall include with this notification instructions
as to how the provider or provider group can access and update
the information using the online interface required by subdivision
(o).

end insert begin insert

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

end insert begin insert

(3) If the plan does not receive an affirmative response and
attestation from the provider that the information is current and
accurate or, as an alternative, updates information required to be
in the directory pursuant to this section, within 30 business days,
the plan shall take investigatory actions as outlined in subdivision
(q) to verify whether the provider’s information is correct or
requires updates. The plan shall complete its investigation and
make any required corrections or updates to the provider directory
based on its investigation within 30 days from the date the provider
was required to provide the affirmative response to the plan. If,
at the completion of its investigation, the plan is unable to verify
whether the provider’s information is correct or requires updates,
the provider shall be removed from the directory. A plan shall
notify the provider 10 days in advance of removal that the provider
will be removed from the directory.

end insert begin insert

(n) This section does not prohibit a plan from requiring its
risk-bearing organizations or contracting specialized health care
plans to satisfy the requirements of this section. If a plan delegates
the responsibility of complying with this section to its risk-bearing
organizations or contracting specialized health care plans, the
plan shall ensure that the requirements of this section are met. A
plan shall retain responsibility for the implementation of this
section, unless that delegated responsibility has been separately
negotiated and specifically documented in written contracts
between the plan and a risk-bearing organization or contracting
specialized health care plan.

end insert begin insert

(o) 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.

end insert begin insert

(p) The plan shall establish and maintain a process for enrollees,
potential enrollees, other providers, and the public to identify and
report possible inaccurate, incomplete, confusing, or misleading
information currently listed in the plan’s provider directory or
directories. These processes shall, at a minimum, include a
telephone number and a dedicated email address at which the plan
will accept these reports, as well as a hyperlink on the plan’s
provider directory Internet Web page linking to a form where the
information can be reported directly to the plan through its Internet
Web site.

end insert begin insert

(q) (1) Whenever a health care service plan receives a report
indicating that information listed in its provider directory or
directories is inaccurate, incomplete, confusing, or misleading,
the plan shall immediately investigate the reported inaccuracy
and, no later than 30 days following receipt of the communication,
either verify the accuracy of the information or update the
information in its provider directory or directories, as applicable.

end insert begin insert

(2) When investigating a communication regarding its provider
directory or directories, the plan shall, at a minimum, do the
following:

end insert begin insert

(A) Contact the affected provider no later than five business
days following receipt of the communication.

end insert begin insert

(B) Document the receipt and outcome of each communication.
The documentation shall include the provider’s name, location,
and a description of the plan’s investigation, the outcome of the
investigation, and any changes or updates made to its provider
directory or directories.

end insert begin insert

(C) If changes to a plan’s provider directory or directories are
required as a result of the plan’s investigation, the changes to the
online provider directory shall be made no later than the next
scheduled weekly update, or the update immediately following that
update, or sooner if required by federal law or regulations. For
printed provider directories, the change shall be made no later
than the next monthly quarterly update, or the monthly quarterly
update immediately following that update.

end insert begin insert

(r) Notwithstanding Sections 1371 and 1371.35, a plan may
delay payment or reimbursement to a provider who has not
responded to the plan’s attempts to verify the provider’s
information. The plan may delay payment or reimbursement for
up to 45 business days in addition to the timeframes for provider
reimbursement pursuant to Sections 1371 and 1371.35. A plan
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.

end insert begin insert

(s) (1) In circumstances where the department finds that an
enrollee reasonably relied upon inaccurate, incomplete, confusing,
or misleading information contained in a health plan’s provider
directory or directories, the department may require the health
plan to provide coverage for all covered health care services
provided to the enrollee and to reimburse the enrollee for any
amount beyond what the enrollee would have paid, had the services
been delivered by an in-network provider under the enrollee’s
plan contract. Prior to requiring reimbursement in these
circumstances, the department must conclude that the services
received by the enrollee were covered services under the enrollee’s
plan contract. In those circumstances, the fact that the services
were rendered or delivered by a noncontracting or out-of-plan
provider shall not be used as a basis to deny reimbursement to the
enrollee.

end insert begin insert

(2) In circumstances where an enrollee in the individual market
reasonably relied upon inaccurate, incomplete, confusing, or
misleading information contained in a health plan’s provider
directory or directories, the plan shall inform the enrollee of the
special enrollment period available under subparagraph (E) of
paragraph (1) of subdivision (d) of Section 1399.845.

end insert begin insert

(3) “Risk-bearing organization” shall have the same meaning
as defined in subdivision (g) of Section 1375.4.

end insert begin insert

(t) 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.

end insert begin insert

(u) 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 insert

(v) Nothing in this section shall be construed to alter a
provider’s obligation to provide health care services to an enrollee
pursuant to the provider’s contract with the plan.

end insert

begin delete

SEC. 2.  

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

1367.28.  

(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 delete

SEC. 3.  

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

10133.15.  

(a)  begin delete Commencing February 1, 2016, a end delete begin insert A end insert health
insurer that contracts with providers for alternative rates of payment
pursuant to Section 10133 shall begin delete make available an online end delete begin insert publish
and maintain end insert provider directory or directories begin delete that provide end delete begin insert with end insert
information on contracting providers that begin delete provide end delete begin insert deliver end insert health
care services to begin delete insureds, end delete begin insert the insurer’s insureds, end insert including those
that accept new begin delete patients pursuant to the requirements of this section
and Section 10133.1. end delete begin insert patients. end insert A provider directory shall not begin insert list
or end insert include information on a provider that begin delete does not have a current end delete
begin insert is not currently under end insert contract with the insurer.

(b) An insurer shall provide the online directory or directories
for the specific network offered for each product using a consistent
method of network and product naming, numbering, or other
classification method that ensures the public, insureds, potential
insureds, the department, and other state or federal agencies can
easily identify begin delete which providers participate in which networks for
which products. An insurer shall use the same consistent naming,
numbering, or 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 naming, numbering, or classification shall be consistent
across products in order to permit multiplan directories. end delete begin insert the
networks and insurer products in which a provider participates.
By July 31, 2017, or six months after the date provider directory
standards are developed under this section, an insurer shall use
the naming, numbering, or classification method developed by the
department pursuant to subdivision (k). end insert

(c)  begin delete The end delete begin insert (1) end insert begin insert   end insert begin insert An end insert online provider directory or directories shall be
available on the insurer’s Internet Web site to the public, potential
insureds, insureds, and providers begin delete through a clearly identifiable link
or tab and in a manner that is accessible and searchable without
any requirement that a member of the public or potential insureds
indicate intent to obtain coverage from the insurer. end delete begin insert without any
restrictions or limitations. end insert The directory or directories shall be
begin delete available to the public without requiring end delete begin insert accessible without any
requirement end insert that an individual seeking the directory information
demonstrate coverage with the insurer, begin insert indicate interest in
obtaining coverage with the insurer, end insert provide a begin insert member
identification or end insert policy number, provide any other identifying
information, or create or access an account.

begin insert

(2) The online 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 insureds, potential insureds, the public, and
providers. The insurer’s public Internet Web site shall allow
provider searches by name, practice address, distance from
specified address, California license number, National Provider
Identifier number, admitting privileges to an identified hospital,
product, tier, provider language, medical group or independent
practice association, hospital name, facility name, or clinic name,
as appropriate.

end insert begin insert

(d) (1) A health insurer shall allow insureds, potential insureds,
and members of the public to request a printed copy of the provider
directory or directories by contacting the insurer through the
insurer’s toll-free telephone number, electronically, or in writing.
A printed copy of the provider directory or directories shall include
the information required in subdivisions (h) and (i). The printed
copy of the provider directory or directories shall be provided to
the insured by mail no later than 15 business days following the
date of the request and may be limited to the geographic region
in which the insured resides or works or intends to reside or work.

end insert begin insert

(2) A health insurer shall update its printed provider directory
or directories at least quarterly, or more frequently, if required
by federal law.

end insert begin delete

(d)

end delete

begin insert (e) end insert  The insurer shall update the online provider directory or
directories, at least begin delete weekly, with any change to contracting
providers, including all of the following: end delete begin insert weekly, or more
frequently, if required by federal law. Any change in information
concerning a listed contracting provider shall be included in the
updated version required by this subdivision. A change in
information includes, but is not limited to, any of the following: end insert

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

(2) Whether the provider begin delete moved or relocated from end delete begin insert relocated
out of end insert the contracted service area of the insurer, or has retired or
has otherwise ceased to begin delete practice, in which case end delete begin insert practice. In all of
these cases, end insert the provider shall be deleted from the directory.

begin insert

(3) Whether the provider is no longer contracted with the insurer
for any reason, in which case the provider shall be deleted from
the directory.

end insert begin insert

(4) Whether the contracted provider is no longer under contract
for a particular product.

end insert begin insert

(5) Whether the provider’s practice location or other
information required under subdivision (h) has changed.

end insert begin delete

(3)

end delete

begin insert (6) end insert  Whether the contracting begin delete provider group, end delete begin insert medical group,
independent practice association, or other group of providers, end insert if
any, has informed the insurer that the provider is no longer
associated with the group and is no longer under contract with the
begin delete plan, end delete begin insert insurer, end insert in which case the provider shall be deleted from the
directory.

begin insert

(7) Whether the contracting medical group, independent practice
association, or other group of providers has informed the insurer
that the provider group is no longer under contract with the
insurer, in which case any provider of the group that does not
maintain an independent contract with the insurer shall be deleted
from the directory.

end insert begin delete

(4)

end delete

begin insert (8) end insert  When the begin delete plan end delete begin insert insurer end insert identified a change is necessary based
on an insured complaint that a provider was not accepting new
patients, was otherwise not available, or whose contact information
was listed incorrectly.

begin delete

(5)

end delete

begin insert (9) end insert  Any other relevant information that has come to the attention
of the product affecting the content and accuracy of the provider
directory.

begin delete

(e)

end delete

begin insert (f) end insert  The begin delete online end delete 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

(f)

end delete

begin insert (g) end insert  The begin delete online end delete provider directory shall include the following
disclosures informing insureds that they are entitled to both of the
following:

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

(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.

begin insert

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

end insert begin insert

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

end insert begin insert

(2) Type of practitioner.

end insert begin insert

(3) National Provider Identifier number.

end insert begin insert

(4) California license number and type of license.

end insert begin insert

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

end insert begin insert

(6) The provider’s office email address, if available.

end insert begin insert

(7) The name of all affiliated medical groups currently under
contract with the insurer through which the provider sees enrollees.

end insert begin insert

(8) A listing for each of the following providers, facilities, and
services that are under contract with the insurer:

end insert begin insert

(A) For physicians and surgeons, the medical group, and
affiliation or admitting privileges, if any, at hospitals contracted
with the insurer.

end insert begin insert

(B) Nurse practitioners, physician assistants, psychologists,
acupuncturists, optometrists, podiatrists, chiropractors, licensed
clinical social workers, marriage and family therapists,
professional clinical counselors, substance abuse counselors,
qualified autism service providers, nurse midwives, and dentists.

end insert begin insert

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

end insert begin insert

(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.

end insert begin insert

(E) Facilities, including but not limited to, general acute care
hospitals, skilled nursing facilities, urgent care clinics, ambulatory
surgery centers, inpatient hospice, residential care facilities, and
inpatient rehabilitation facilities.

end insert begin insert

(F) Pharmacies, clinical laboratories, imaging centers, and
other facilities providing contracted health care services.

end insert begin insert

(9) The provider directory may note that authorization or
referral may be required to access some providers.

end insert begin insert

(10) Non-English language, if any, spoken by a health care
provider or other medical professional as well as non-English
language spoken by a qualified medical interpreter, in accordance
with Section 1367.04 of the Health and Safety Code, if any, on the
provider’s staff.

end insert begin insert

(11) Identification of providers who no longer accept new
patients for one or more of the insurer’s products or for all of the
insurer’s products.

end insert begin insert

(12) Network tier to which the provider is assigned, if the
provider is not in the lowest tier, as applicable. Nothing in this
section shall be construed to require the use of network tiers other
than contract and noncontracting tiers.

end insert begin insert

(13) All other information necessary to conduct a search
pursuant to paragraph (2) of subdivision (c).

end insert begin insert

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

end insert begin insert

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

end insert begin insert

(2) Type of practitioner.

end insert begin insert

(3) National Provider Identifier number.

end insert begin insert

(4) California license number and type of license, if applicable.

end insert begin insert

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

end insert begin insert

(6) The provider’s office email address, if available.

end insert begin insert

(7) The name of any affiliated medical group, independent
practice association, or specialty insurer practice group currently
under contract with the insurer through which the provider sees
insureds.

end insert begin insert

(8) 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.

end insert begin insert

(9) Non-English language, if any, spoken by a health care
provider or other medical professional as well as non-English
language spoken by a qualified medical interpreter, in accordance
with Section 1367.04 of the Health and Safety Code, if any, on the
provider’s staff.

end insert begin insert

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

end insert begin insert

(k) (1) On or before December 31, 2016, the department shall
develop uniform provider directory standards for purposes of this
section. Those standards shall not be subject to the Administrative
Procedure Act (Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code), until
January 1, 2021.

end insert begin insert

(2) In developing the standards under this subdivision, the
department shall seek input from interested parties and shall hold
at least one public meeting. The department shall take into
consideration any requirements for provider directories established
by the federal Centers for Medicare and Medicaid Services.

end insert begin insert

(3) By July 31, 2017, or six months after the date provider
directory standards are developed under this subdivision,
whichever occurs later, an insurer shall use the standards
developed by the department for each product offered by the
insurer.

end insert begin insert

(l) An insurer shall establish policies and procedures with
regard to the regular updating of its provider directory or
directories, including the weekly, quarterly, and annual updates
required pursuant to this section, or more frequently, if required
by federal law or guidance.

end insert begin insert

(m) The policies and procedures established under this
subdivision shall be submitted by an insurer annually to the
department for approval and in a format described by the
department.

end insert begin insert

(1) At a minimum, these policies and procedures shall include
all of the following:

end insert begin insert

(A) At least annually, the insurer shall review and update the
entire provider directory or directories for each product offered.

end insert begin insert

(B) At least quarterly, the insurer shall notify the contracted
provider or provider group, if applicable, of the information the
insurer has in the directory or directories on the provider or
provider group contained in the directory, including a list of
networks and insurer products that include the contracted provider
or provider group. The insurer shall include with this notification
instructions as to how the provider or provider group can access
and update the information using the online interface required by
subdivision (o).

end insert begin insert

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

end insert begin insert

(3) If the insurer does not receive an affirmative response and
attestation from the provider that the information is current and
accurate or, as an alternative, updates information required to be
in the directory pursuant to this section, within 30 business days,
the insurer shall take investigatory actions as outlined in
subdivision (q) to verify whether the provider’s information is
correct or requires updates. The insurer shall complete its
investigation and make any required corrections or updates to the
provider directory based on its investigation within 30 days from
the date the provider was required to provide the affirmative
response to the insurer. If, at the completion of its investigation,
the insurer is unable to verify whether the provider’s information
is correct or requires updates, the provider shall be removed from
the directory. An insurer shall notify the provider 10 days in
advance of removal that the provider will be removed from the
directory.

end insert begin insert

(n) This section does not prohibit an insurer from requiring its
risk-bearing organizations or contracting specialized health
insurers to satisfy the requirements of this section. If an insurer
delegates the responsibility of complying with this section to its
risk-bearing organizations or contracting specialized health
insurers, the insurer shall ensure that the requirements of this
section are met. An insurer shall retain responsibility for the
implementation of this section, unless that delegated responsibility
has been separately negotiated and specifically documented in
written contracts between the insurer and a risk-bearing
organization or contracting specialized health insurer.

end insert begin insert

(o) Every health insurer shall ensure processes are in place to
allow providers to promptly verify or submit changes to the
information required to be in the directory 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 health insurer.

end insert begin insert

(p) The insurer shall establish and maintain a process for
insureds, potential insureds, other providers, and the public to
identify and report possible inaccurate, incomplete, confusing, or
misleading information currently listed in the insurer’s provider
directory or directories. These processes shall, at a minimum,
include a telephone number and a dedicated email address at
which the insurer will accept these reports, as well as a hyperlink
on the insurer’s provider directory Internet Web page linking to
a form where the information can be reported directly to the
insurer through its Internet Web site.

end insert begin insert

(q) (1) Whenever a health insurer receives a report indicating
that information listed in its provider directory or directories is
inaccurate, incomplete, confusing, or misleading, the insurer shall
immediately investigate the reported inaccuracy and, no later than
30 days following receipt of the communication, either verify the
accuracy of the information or update the information in its
provider directory or directories, as applicable.

end insert begin insert

(2) When investigating a communication regarding its provider
directory or directories, the insurer shall, at a minimum, do the
following:

end insert begin insert

(A) Contact the affected provider no later than five business
days following receipt of the communication.

end insert begin insert

(B) Document the receipt and outcome of each communication.
The documentation shall include the provider’s name, location,
and a description of the insurer’s investigation, the outcome of
the investigation, and any changes or updates made to its provider
directory or directories.

end insert begin insert

(C) If changes to an insurer’s provider directory or directories
are required as a result of the insurer’s investigation, the changes
to the online provider directory shall be made no later than the
next scheduled weekly update, or the update immediately following
that update, or sooner if required by federal law or regulations.
For printed provider directories, the change shall be made no
later than the next monthly quarterly update, or the monthly
quarterly update immediately following that update.

end insert begin insert

(r) Notwithstanding Section 10123.13, an insurer may delay
payment or reimbursement to a provider who has not responded
to the insurer’s attempts to verify the provider’s information. The
insurer may delay payment or reimbursement for up to 45 business
days in addition to the timeframes for provider reimbursement
pursuant to Section 10123.13. An 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.

end insert begin insert

(s) (1) In circumstances where the department finds that an
insured reasonably relied upon inaccurate, incomplete, confusing,
or misleading information contained in an insurer’s provider
directory or directories, the department may require the insurer
to provide coverage for all covered health care services provided
to the insured and to reimburse the insured for any amount beyond
what the insured would have paid, had the services been delivered
by an in-network provider under the insured’s insurance contract.
Prior to requiring reimbursement in these circumstances, the
department must conclude that the services received by the insured
were covered services under the insured’s insurance contract. In
those circumstances, the fact that the services were rendered or
delivered by a noncontracting or out-of-network provider shall
not be used as a basis to deny reimbursement to the insured.

end insert begin insert

(2) In circumstances where an insured in the individual market
reasonably relied upon inaccurate, incomplete, confusing, or
misleading information contained in an insurer’s provider
directory or directories, the insurer shall inform the insured of the
special enrollment period available under subparagraph (E) of
paragraph (1) of subdivision (d) of Section 10965.3.

end insert begin insert

(3) “Risk-bearing organization” shall have the same meaning
as defined in subdivision (g) of Section 1375.4 of the Health and
Safety Code.

end insert begin insert

(t) 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 insert

(u) Nothing in this section shall be construed to alter a
provider’s obligation to provide health care services to an insured
pursuant to the provider’s contract with the insurer.

end insert

begin delete

SEC. 4.  

Section 10133.16 is added to the Insurance Code, to
read:

10133.16.  

(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 delete

begin delete SEC. 5. end delete
begin insert SEC. 4. 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.