Amended in Assembly August 31, 2015

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 Section 1367.27 to, and begin insert to end insert repeal Section 1367.26 of, the Health and Safety Code, and to add Section 10133.15 to the Insurance Code, relating to health care coverage.

LEGISLATIVE COUNSEL’S DIGEST

SB 137, as amended, Hernandez. Health care coverage: provider directories.

Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care. A willful violation of the act is a crime. Existing law requires a health care service plan to provide a list of contracting providers within a requesting enrollee’s or prospective enrollee’s general geographic area.

Existing law also provides for the regulation of health insurers by the Insurance Commissioner. Existing law requires begin insert health end insert 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.

This begin delete bill end delete begin insert bill, commencing July 1, 2016, end insert would require begin insert a end insert health care service begin delete plans, and insurers subject to regulation by the commissioner for services at alternative rates, to end delete begin insert plan, and a health insurer that contracts with providers for alternative rates of payment, to publish and maintain a provider directory or directories with information on contracting providers that deliver health care services to the plan’s enrollees or the health insurer’s insureds, and would require the plan or health insurer to end insert make an online provider directory begin insert or directories end insert available on begin delete its end delete begin insert the plan or health insurer’s end insert Internet Web site, as specified.

This bill would require the Department of Managed Health Care and the Department of Insurance to jointly develop uniform provider directory standards. The bill would require begin delete 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, as specified. end delete begin insert a health care service plan or health insurer to take appropriate steps to ensure the accuracy of the information contained in the plan or health insurer’s directory or directories, and would require the plan or health insurer, at least annually, to review and update the entire provider directory or directories for each product offered, as specified. The bill would require a plan or insurer, at least weekly, to update its online provider directory or directories, and would require a plan or insurer, at least quarterly, to update its printed provider directory or directories. end insert The bill would require a health care service plan or begin insert health end insert insurer to reimburse an enrollee or insured for any amount beyond what the begin delete enrollee, end delete begin insert enrollee end insert or insured would have paid for in-network services, if the enrollee or insured reasonably relied on the provider directory, as specified. 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 1367.26 of the Health and Safety Code
is repealed.

SEC. 2.  

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

1367.27.  

(a)  begin delete A end delete begin insert Commencing July 1, 2016, a end insert health care service
plan shall publish and maintain a provider directory or directories
with information on contracting providers that deliver health care
services to the plan’s enrollees, including those that accept new
patients. A provider directory shall not list or include information
on a provider that is not currently under contract with the plan.

(b) A health care service plan shall provide the directory or
directories for the specific network offered for each product using
a consistent method of network and product naming, numbering,
or other classification method that ensures the public, enrollees,
potential enrollees, the department, and other state or federal
agencies can easily identify the networks and plan products in
which a provider participates. By July 31, 2017, or begin delete six end delete begin insert 12 end insert months
after the date provider directory standards are developed under
begin delete this section, end delete begin insert subdivision (k), whichever occurs later, end insert a health care
service plan shall use the naming, numbering, or classification
method developed by the department pursuant to subdivision (k).

(c) (1) An online provider directory or directories shall be
available on the plan’s Internet Web site to the public, potential
enrollees, enrollees, and providers without any restrictions or
limitations. The directory or directories shall be accessible without
any requirement that an individual seeking the directory
information demonstrate coverage with the plan, indicate interest
in obtaining coverage with the plan, provide a member
identification or policy number, provide any other identifying
information, or create or access an account.

(2) The online provider directory or directories shall be
accessible on the plan’s public Internet Web site through begin delete a clearly end delete
begin insert an end insert identifiable link or tab and in a manner that is accessible and
searchable by enrollees, potential enrollees, the public, and
providers. begin delete The end delete begin insert By July 31, 2017, or twelve months after the date
provider directory standards are developed under subdivision (k),
whichever occurs later, the end insert plan’s public Internet Web site shall
allow provider searches begin delete by end delete begin insert by, at a minimum, end insert name, practice
address, begin delete distance from specified address, end delete begin insert city, ZIP Code, end insert California
license number, National Provider Identifier number, admitting
privileges to an identified hospital, product, tier, provider begin delete language,
medical group or independent practice association, end delete begin insert language or
languages, provider group, end insert hospital name, facility name, or clinic
name, as appropriate.

(d) (1) A health care service plan shall allow enrollees, potential
enrollees, begin insert providers, end insert 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 begin delete enrollee end delete begin insert requester end insert by mail begin insert postmarked end insert no later
than begin delete 15 end delete begin insert five end insert business days following the date of the request and
may be limited to the geographic region in which the begin delete enrollee end delete
begin insert requester end insert resides or works or intends to reside or work.

(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.

(e)  begin insert (1) end insert begin insert   end insert The plan shall update the online provider directory or
directories, at least weekly, or more frequently, if required by
federal begin delete 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, end delete begin insert law, when informed of and upon confirmation
by the plan of end insert any of the following:

begin delete

(1) Whether a

end delete

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

begin delete

(2) Whether the provider relocated out of the contracted service
area of the plan, has retired, or has otherwise ceased to practice.
In all of these cases, the provider shall be deleted from the
directory.

(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.

(4) Whether the contracted

end delete

begin insert (B) end insert begin insert   end insert begin insert A end insert provider is no longer under contract for a particular begin insert plan end insert
product.

begin delete

(5) Whether the

end delete

begin insert (C) end insert begin insert   end insert begin insert A end insert provider’s practice location or other information required
under subdivision (h) begin insert or (i) end insert has changed.

begin delete

(6) Whether the contracting medical group, independent practice
association, or other group of providers, 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.

(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.

(8) When the plan identified

end delete

begin insert (D) end insert begin insert   end insert begin insert Upon completion of the investigation described in
subdivision (o), end insert 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

(9) Any other relevant information that has come to the attention
of the plan affecting

end delete

begin insert (E) end insert begin insert   end insert begin insert Any other information that affects end insert the content begin delete and end delete begin insert or end insert
accuracy of the provider begin delete directory. end delete begin insert directory or directories. end insert

begin insert

(2) Upon confirmation of any of the following, the plan shall
delete a provider from the directory or directories when:

end insert begin insert

(A) A provider has retired or otherwise has ceased to practice.

end insert begin insert

(B) A provider or provider group is no longer under contract
with the plan for any reason.

end insert begin insert

(C) The contracting provider group has informed the plan that
the provider is no longer associated with the provider group and
is no longer under contract with the plan.

end insert

(f) The provider directory or directories shall include both an
email address and a telephone number for members of the public
and providers to notify the plan if the provider directory
information appears to be inaccurate. begin insert This information shall be
disclosed prominently in the directory or directories and on the
plan’s Internet Web site. end insert

(g) The provider directory begin insert or directories end insert 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 begin delete services. end delete begin insert services in
accordance with Section 1367.04. end 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.

(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:

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

(7) The name of begin delete all end delete begin insert each end insert affiliated begin delete medical groups end delete begin insert provider
group end insert currently under contract with the plan through which the
provider sees enrollees.

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

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

(B) Nurse practitioners, physician assistants, psychologists,
acupuncturists, optometrists, podiatrists, chiropractors, licensed
clinical social workers, marriage and family therapists, professional
clinical counselors, begin delete substance abuse counselors, end delete qualified autism
service providers, begin insert as defined in Section 1374.73, end insert nurse midwives,
and dentists.

(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) 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.

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

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

(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.

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

(12)  begin delete Network end delete begin insert The network end insert 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.

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

(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 begin delete of the end delete provider begin insert directory or end insert
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, if applicable.

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

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

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

(8) The names of begin delete any end delete begin insert each end insert allied health care begin delete professionals end delete
begin insert professional end insert to the extent there is a direct contract for those services
covered through begin delete the end delete begin insert a end insert contract with the plan.

(9)  begin delete Non-English end delete begin insert The non-English end insert 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.

begin insert

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

end insert begin insert

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

end insert begin insert

(j) (1) The contract between the plan and a provider shall
include a requirement that the provider inform the plan within five
business days when either of the following occur:

end insert begin insert

(A) The provider is not accepting new patients.

end insert begin insert

(B) If the provider had previously not accepted new patients,
the provider is currently accepting new patients.

end insert begin insert

(2) If a provider who is not accepting new patients is contacted
by an enrollee or potential enrollee seeking to become a new
patient, the provider shall direct the enrollee or potential enrollee
to the plan for additional assistance in finding a provider and the
provider shall provide information to the individual on how to
contact the department to report any inaccuracy with the plan’s
directory or directories.

end insert begin delete

(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

end delete

begin insert (3) end insert begin insert   end insert begin insert If end insert an enrollee or potential enrollee informs a plan of a
possible inaccuracy in the provider directory or directories, the
plan shall begin delete immediately end delete begin insert promptly end insert investigate, and, if necessary,
undertake corrective action within 30 business days to ensure the
accuracy of the directory or directories.

(k) (1) On or before December 31, 2016, the department shall
develop uniform provider directory standards begin delete for purposes of this
section. end delete begin insert to permit consistency in accordance with subdivision (b)
and paragraph (2) of subdivision (c) and development of a
multi-plan directory by another entity. end insert 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. begin insert No more than
two revisions of those standards shall be exempt from the
Administrative Procedure Act (Chapter 3.5 (commencing with
Section 11340) of Part 1 of Division 3 of Title 2 of the Government
Code) pursuant to this subdivision. end insert

(2) In developing the standards under this subdivision, the
department shall seek input from interested parties begin insert throughout the
process of developing the standards end insert 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 begin delete Services. end delete begin insert Services and the
State Department of Health Care Services. end insert

(3) By July 31, 2017, or begin delete six end delete begin insert 12 end insert 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.

begin insert

(l) (1) A plan shall take appropriate steps to ensure the
accuracy of the information concerning each provider listed in
the plan’s provider directory or directories in accordance with
this section, and shall, at least annually, review and update the
entire provider directory or directories for each product offered.
Each calendar year the plan shall notify all contracted providers
described in subdivisions (h) and (i) as follows:

end insert begin insert

(A) For individual providers who are not affiliated with a
provider group described in subparagraph (A) or (B) of paragraph
(8) of subdivision (h) and providers described in subdivision (i),
the plan shall notify each provider at least once every six months.

end insert begin insert

(B) For all other providers described in subdivision (h) who
are not subject to the requirements of subparagraph (A), the plan
shall notify its contracted providers to ensure that all of the
providers are contacted by the plan at least once annually.

end insert begin insert

(2) The notification shall include all of the following:

end insert begin insert

(A) The information the plan has in its directory or directories
regarding the provider or provider group, including a list of
networks and plan products that include the contracted provider
or provider group.

end insert begin insert

(B) A statement that the failure to respond to the notification
may result in a delay of payment or reimbursement of a claim
pursuant to subdivision (p).

end insert begin insert

(C) Instructions on how the provider or provider group can
update the information in the provider directory or directories
using the online interface developed pursuant to subdivision (m).

end insert begin insert

(3) 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 confirm that
the information in the provider directory or directories is current
and accurate or update the information required to be in the
directory or directories 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

(4) If the plan does not receive an affirmative response and
confirmation from the provider that the information is current and
accurate or, as an alternative, updates any information required
to be in the directory or directories pursuant to this section, within
30 business days, the plan shall take no more than 15 business
days to verify whether the provider’s information is correct or
requires updates. The plan shall document the receipt and outcome
of each attempt to verify the information. If the plan is unable to
verify whether the provider’s information is correct or requires
updates, the plan shall notify the provider 10 business days in
advance of removal that the provider will be removed from the
provider directory or directories. The provider shall be removed
from the provider directory or directories at the next required
update of the provider directory or directories after the 10-business
day notice period. A provider shall not be removed from the
provider directory or directories if he or she responds before the
end of the 10-business day notice period.

end insert begin delete

(l)

end delete

begin insert (m) end insert  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.

begin delete

(m)

end delete

begin insert (1) end insert  The policies and procedures begin delete established end delete begin insert described end insert under
begin delete this end delete subdivision begin insert (l) end insert 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.

begin delete

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

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

(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).

(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.

(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.

(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.

(o)

end delete

begin insert (2) end insert  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 begin insert or directories end insert
pursuant to this section. Those processes shall, at a minimum,
include an online interface for providers to submit verification or
changes electronically and shall begin delete allow providers to receive end delete begin insert generate end insert
an acknowledgment of receipt from the health care service plan.
Providers shall verify or submit changes to information required
to be in the directory begin insert or directories end insert pursuant to this section using
the process required by the health begin insert care service end insert plan.

begin delete

(p)

end delete

begin insert (3) end insert  The plan shall establish and maintain a process for enrollees,
potential enrollees, other providers, and the public to identify and
report possible inaccurate, incomplete, begin delete confusing, end delete 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 begin delete page end delete begin insert site end insert linking to a form where
the information can be reported directly to the plan through its
Internet Web site.

begin insert

(n) (1) This section does not prohibit a plan from requiring its
provider groups or contracting specialized health care service
plans to provide information to the plan that is required by the
plan to satisfy the requirements of this section for each of the
providers that contract with the provider group or contracting
specialized health care service plan. This responsibility shall be
specifically documented in a written contract between the plan
and the provider group or contracting specialized health care
service plan.

end insert begin insert

(2) If a plan requires its contracting provider groups or
contracting specialized health care service plans to provide the
plan with information described in paragraph (1), the plan shall
continue to retain responsibility for ensuring that the requirements
of this section are satisfied.

end insert begin delete

(q)

end delete

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

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

(A) Contact the affected provider no later than five business
days following receipt of the begin delete communication. end delete begin insert report. end insert

(B) Document the receipt and outcome of each begin delete communication. end delete
begin insert report. end insert 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.

(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 begin insert or directories end insert 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 begin delete monthly quarterly end delete begin insert required end insert update, or
begin delete the monthly quarterly update immediately following that update. end delete
begin insert sooner if required by federal law or regulations. end insert

begin delete

(r) Notwithstanding

end delete

begin insert (p) end insert begin insert   end insert begin insert (1) end insert begin insert   end insert begin insert Commencing July 1, 2017, notwithstanding end insert Sections
1371 and 1371.35, a plan may delay payment or reimbursement
begin delete to a provider who has not responded end delete begin insert owed to a provider or provider
group as specified in subparagraph (A) or (B), if the provider or
provider group fails to respond end insert to the plan’s attempts to verify the
begin delete provider’s information. The end delete begin insert provider or provider group’s
information as required under subdivision (l). The plan shall not
delay payment unless it has attempted to verify the provider’s or
provider group’s information by all means of communication
available to the plan, including in writing, electronically, or by
telephone. A plan may seek to delay payment or reimbursement
owed to a provider or provider group only after the 10-business
day notice period described in paragraph (4) of subdivision (l)
has lapsed. end insert

begin insert (A) end insert begin insert   end insert begin insert For a provider or provider group that receives
compensation on a capitated or prepaid basis, the end insert plan may delay
begin delete 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 end delete begin insert the next scheduled capitation payment
for up to one calendar month. end insert

begin insert

(B) For any claims payment made to a provider or provider
group, the plan may delay the claims payment for up to one
calendar month beginning on the first day of the following month.

end insert begin insert

(2) A plan shall notify the provider or provider group 10
business days before it seeks to delay payment or reimbursement
to a provider or provider group pursuant to this subdivision. If
the plan delays a payment or reimbursement pursuant to this
subdivision, the plan shall reimburse the full amount of any
payment or reimbursement subject to delay to the provider or
provider group no later than three business days following the
date on which the plan receives the information required to be
submitted by the provider or provider group pursuant to
subdivision (l).

end insert

begin insert (3) end insert begin insert   end insert begin insert A plan end insert 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 begin insert or
directories end insert pursuant to this section.

begin insert

(4) With respect to plans with Medi-Cal managed care contracts
with the State Department of Health Care Services pursuant to
Chapter 7 (commencing with Section 14000), Chapter 8
(commencing with Section 14200), or Chapter 8.75 (commencing
with Section 14591) of the Welfare and Institutions Code, this
subdivision shall be implemented only to the extent consistent with
federal law and guidance.

end insert begin delete

(s) (1) In

end delete

begin insert (q end insert begin insert ) end insert begin insert   end insert begin insert In end insert circumstances where the department finds that an enrollee
reasonably relied upon begin insert materially end insert inaccurate, incomplete,
begin delete confusing, end delete 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 begin delete must end delete begin insert shall end insert 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.

begin delete

(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 delete begin delete

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

end delete begin insert

(r) Whenever a plan determines as a result of this section that
there has been a 10-percent change in the network for a product
in a region, the plan shall file an amendment to the plan
application with the department consistent with subdivision (f) of
Section 1300.52 of Title 28 of the California Code of Regulations.

end insert begin delete

(t)

end delete

begin insert (s) end insert  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 begin delete 14000) or end delete begin insert 14000), end insert
Chapter 8 (commencing with Section begin delete 14200) end delete begin insert 14200), or Chapter
8.75 (commencing with Section 14591) end insert of the Welfare and
Institutions Code to the extent consistent with federal law and
begin delete guidance. end delete begin insert guidance and state law guidance issued after January
1, 2016. Notwithstanding any other provision to the contrary in a
plan contract with the State Department of Health Care Services,
and to the extent consistent with federal law and guidance and
state guidance issued after January 1, 2016, a Medi-Cal managed
care plan that complies with the requirements of this section shall
not be required to distribute a printed provider directory or
directories, except as required by paragraph (1) of subdivision
(d). end insert

begin delete

(u)

end delete

begin insert (t) end insert  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.

begin delete

(v)

end delete

begin insert (u) end insert  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.

begin insert

(v) For purposes of this section, “provider group” means a
medical group, independent practice association, or other similar
group of providers.

end insert

SEC. 3.  

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

10133.15.  

(a)  begin delete A end delete begin insert Commencing July 1, 2016, a end insert health insurer
that contracts with providers for alternative rates of payment
pursuant to Section 10133 shall publish and maintain provider
directory or directories with information on contracting providers
that deliver health care services to the insurer’s insureds, including
those that accept new patients. A provider directory shall not list
or include information on a provider that is not currently under
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 the networks and insurer products in which a
provider participates. By July 31, 2017, or begin delete six end delete begin insert 12 end insert months after the
date provider directory standards are developed under begin delete this section, end delete
begin insert subdivision (k), whichever occurs later, end insert an insurer shall use the
naming, numbering, or classification method developed by the
department pursuant to subdivision (k).

(c) (1) An online provider directory or directories shall be
available on the insurer’s Internet Web site to the public, potential
insureds, insureds, and providers without any restrictions or
limitations. The directory or directories shall be accessible without
any requirement that an individual seeking the directory
information demonstrate coverage with the insurer, indicate interest
in obtaining coverage with the insurer, provide a member
identification or policy number, provide any other identifying
information, or create or access an account.

(2) The online provider directory or directories shall be
accessible on the insurer’s public Internet Web site through begin delete a
clearly end delete begin insert an end insert identifiable link or tab and in a manner that is accessible
and searchable by insureds, potential insureds, the public, and
providers. begin delete The end delete begin insert By July 1, 2017, or 12 months after the date
provider directory standards are developed under subdivision (k),
whichever occurs later, the end insert insurer’s public Internet Web site shall
allow provider searches begin delete by end delete begin insert by, at a minimum, end insert name, practice
address, begin delete distance from specified address, end delete begin insert city, ZIP Code, end insert California
license number, National Provider Identifier number, admitting
privileges to an identified hospital, product, tier, provider begin delete language,
medical group or independent practice association, end delete begin insert language or
languages, provider group, end insert hospital name, facility name, or clinic
name, as appropriate.

(d) (1)  begin delete A health end delete begin insert An end insert insurer shall allow insureds, potential
insureds, begin insert providers, end insert 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 begin delete insured end delete begin insert requester end insert by mail
begin insert postmarked end insert no later than begin delete 15 end delete begin insert five end insert business days following the date
of the request and may be limited to the geographic region in which
the begin delete insured end delete begin insert requester end insert resides or works or intends to reside or work.

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

(e)  begin insert (1) end insert begin insert   end insert The insurer shall update the online provider directory
or directories, at least weekly, or more frequently, if required by
federal begin delete 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, end delete begin insert law, when informed of and upon confirmation
by the insurer of end insert any of the following:

begin delete

(1) Whether a

end delete

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

begin delete

(2) Whether the provider relocated out of the contracted service
area of the insurer, or has retired or has otherwise ceased to
practice. In all of these cases, the provider shall be deleted from
the directory.

end delete begin delete

(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 delete begin delete

(4) Whether the

end delete

begin insert (B) end insert begin insert   end insert begin insert A end insert contracted provider is no longer under contract for a
particular product.

begin delete

(5) Whether the

end delete

begin insert (C) end insert begin insert   end insert begin insert A end insert provider’s practice location or other information required
under subdivision (h) begin insert or (i) end insert has changed.

begin delete

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

(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.

(8) When the insurer identified

end delete

begin insert (D) end insert begin insert   end insert begin insert Upon the completion of the investigation described in
subdivision (o), end insert 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

(9) Any other relevant information that has come to the attention
of the product affecting

end delete

begin insert (E) end insert begin insert   end insert begin insert Any other information that affects end insert the content begin delete and end delete begin insert or end insert
accuracy of the provider begin delete directory. end delete begin insert directory or directories. end insert

begin insert

(2) Upon confirmation of any of the following, the insurer shall
delete a provider from the directory or directories when:

end insert begin insert

(A) A provider has retired or otherwise has ceased to practice.

end insert begin insert

(B) A provider or provider group is no longer under contract
with the insurer for any reason.

end insert begin insert

(C) The contracting provider group has informed the insurer
that the provider is no longer associated with the provider group
and is no longer under contract with the insurer.

end insert

(f) The provider directory or directories shall include both an
email address and a telephone number for members of the public
and providers to notify the insurer if the provider directory
information appears to be inaccurate. begin insert This information shall be
disclosed prominently in the directory or directories and on the
insurer’s Internet Web site. end insert

(g) The provider directory begin insert or directories end insert 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 begin delete services. end delete begin insert services in
accordance with Section 10133.8. end 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.

(h) The begin delete health end delete insurer and a specialized mental health 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) The provider’s office email address, if available.

(7) The name of begin delete all end delete begin insert each end insert affiliated begin delete medical groups end delete begin insert provider
group end insert currently under contract with the insurer through which the
provider sees enrollees.

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

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

(B) Nurse practitioners, physician assistants, psychologists,
acupuncturists, optometrists, podiatrists, chiropractors, licensed
clinical social workers, marriage and family therapists, professional
clinical counselors, begin delete substance abuse counselors, end delete qualified autism
service providers, begin insert as defined in Section 10144.51, end insert nurse midwives,
and dentists.

(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) 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.

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

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

(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 begin delete 1367.04 of the Health and Safety Code, end delete begin insert 10133.8 of
the Insurance Code, end insert if any, on the provider’s staff. begin insert For purposes
of this section, “qualified interpreter” means that the interpreter
meets the proficiency standards established pursuant to
subparagraph (H) of paragraph (2) of subdivision (c) of Section
1300.67.04 of Title 28 of the California Code of Regulations. end insert

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

(12)  begin delete Network end delete begin insert The network end insert 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.

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

(i) A vision, dental, or other specialized insurer, except for a
specialized mental health insurer, shall include all of the following
information for each begin delete of the end delete provider begin insert directory or end insert 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, if applicable.

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

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

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

(8) The names of begin delete any end delete begin insert each end insert allied health care begin delete professionals end delete
begin insert professional end insert to the extent there is a direct contract for those services
covered through begin delete the end delete begin insert a end insert contract with the insurer.

(9)  begin delete Non-English end delete begin insert The non-English end insert 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 begin delete 1367.04 of the Health and Safety end delete
begin insert 10133.8 of the Insurance end insert Code, if any, on the provider’s staff. begin insert For
purposes of this section, “qualified interpreter” means that the
interpreter meets the proficiency standards established pursuant
to subparagraph (H) of paragraph (2) of subdivision (c) of Section
1300.67.04 of Title 28 of the California Code of Regulations. end insert

begin insert

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

end insert begin insert

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

end insert begin insert

(j) (1) The contract between the insurer and a provider shall
include a requirement that the provider inform the insurer within
five business days when either of the following occur:

end insert begin insert

(A) The provider is not accepting new patients.

end insert begin insert

(B) If the provider had previously not accepted new patients,
the provider is currently accepting new patients.

end insert begin insert

(2) If a provider who is not accepting new patients is contacted
by an insured or potential insured seeking to become a new patient,
the provider shall direct the insurer or potential insured to the
insurer for additional assistance in finding a provider and the
provider shall provide information to the individual on how to
contact the department to report any inaccuracy with the insurer’s
directory or directories.

end insert begin delete

(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

end delete

begin insert (3) end insert begin insert   end insert begin insert If end insert an insured or potential insured informs an insurer of a
possible inaccuracy in the provider directory or directories, the
insurer shall begin delete immediately end delete begin insert promptly end insert investigate and, if necessary,
undertake corrective action within 30 business days to ensure the
accuracy of the directory or directories.

(k) (1) On or before December 31, 2016, the department shall
develop uniform provider directory standards begin delete for purposes of this
section. end delete begin insert to permit consistency in accordance with subdivision (b)
and paragraph (2) of subdivision (c) and development of a
multiplan directory by another entity. end insert 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. begin insert No more than
two revisions of those standards shall be exempt from the
Administrative Procedure Act (Chapter 3.5 (commencing with
Section 11340) of Part 1 of Division 3 of Title 2 of the Government
Code) pursuant to this subdivision. end insert

(2) In developing the standards under this subdivision, the
department shall seek input from interested parties begin insert throughout the
process of developing the standards end insert 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 begin delete Services. end delete begin insert Services and the
State Department of Health Care Services. end insert

(3) By July 31, 2017, or begin delete six end delete begin insert 12 end insert 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.

begin insert

(l) (1) An insurer shall take appropriate steps to ensure the
accuracy of the information concerning each provider listed in
the insurer’s provider directory or directories in accordance with
this section, and shall, at least annually, review and update the
entire provider directory or directories for each product offered.
Each calendar year the insurer shall notify all contracted providers
described in subdivisions (h) and (i) as follows:

end insert begin insert

(A) For individual providers who are not affiliated with a
provider group described in subparagraph (A) or (B) of paragraph
(8) of subdivision (h) and providers described in subdivision (i),
the insurer shall notify each provider at least once every six
months.

end insert begin insert

(B) For all other providers described in subdivision (h) who
are not subject to the requirements of subparagraph (A), the
insurer shall notify its contracted providers to ensure that all of
the providers are contacted by the insurer at least once annually.

end insert begin insert

(2) The notification shall include all of the following:

end insert begin insert

(A) The information the insurer has in its directory or directories
regarding the provider or provider group, including a list of
networks and products that include the contracted provider or
provider group.

end insert begin insert

(B) A statement that the failure to respond to the notification
may result in a delay of payment or reimbursement of a claim
pursuant to subdivision (p).

end insert begin insert

(C) Instructions on how the provider or provider group can
update the information in the provider directory or directories
using the online interface developed pursuant to subdivision (m).

end insert begin insert

(3) 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 confirm that
the information in the provider directory or directories is current
and accurate or update the information required to be in the
directory or directories pursuant to this section, including whether
or not the provider group is accepting new patients for each
product.

end insert begin insert

(4) If the insurer does not receive an affirmative response and
confirmation from the provider that the information is current and
accurate or, as an alternative, updates any information required
to be in the directory or directories pursuant to this section, within
30 business days, the insurer shall take no more than 15 business
days to verify whether the provider’s information is correct or
requires updates. The insurer shall document the receipt and
outcome of each attempt to verify the information. If the insurer
is unable to verify whether the provider’s information is correct
or requires updates, the insurer shall notify the provider 10
business days in advance of removal that the provider will be
removed from the directory or directories. The provider shall be
removed from the directory or directories at the next required
update of the provider directory or directories after the 10-business
day notice period. A provider shall not be removed from the
provider directory or directories if he or she responds before the
end of the 10-business day notice period.

end insert begin delete

(l)

end delete

begin insert (m) end insert  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.

begin delete

(m)

end delete

begin insert (1) end insert  The policies and procedures begin delete established end delete begin insert described end insert under
begin delete this end delete subdivision begin insert (l) end insert shall be submitted by an insurer annually to
the department for approval and in a format described by the
department.

begin delete

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

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

(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).

(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.

(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.

(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.

(o)

end delete

begin insert (2) end insert  Every begin delete health end delete 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 begin insert or directories end insert pursuant
to this section. Those processes shall, at a minimum, include an
online interface for providers to submit verification or changes
electronically and shall begin delete allow providers to receive end delete begin insert generate end insert an
acknowledgment of receipt from the begin delete health end delete insurer. Providers shall
verify or submit changes to information required to be in the
directory begin insert or directories end insert pursuant to this section using the process
required by the begin delete health end delete insurer.

begin delete

(p)

end delete

begin insert (3) end insert  The insurer shall establish and maintain a process for
insureds, potential insureds, other providers, and the public to
identify and report possible inaccurate, incomplete, begin delete confusing, end delete 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 begin delete page end delete begin insert site end insert linking to a
form where the information can be reported directly to the insurer
through its Internet Web site.

begin insert

(n) (1) This section does not prohibit an insurer from requiring
its provider groups or contracting specialized health insurers to
provide information to the insurer that is required by the insurer
to satisfy the requirements of this section for each of the providers
that contract with the provider group or contracting specialized
health insurer. This responsibility shall be specifically documented
in a written contract between the insurer and the provider group
or contracting specialized health insurer.

end insert begin insert

(2) If an insurer requires its contracting provider groups or
contracting specialized health insurers to provide the insurer with
information described in paragraph (1), the insurer shall continue
to retain responsibility for ensuring that the requirements of this
section are satisfied.

end insert begin delete

(q)

end delete

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

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

(A) Contact the affected provider no later than five business
days following receipt of the begin delete communication. end delete begin insert report. end insert

(B) Document the receipt and outcome of each begin delete communication. end delete
begin insert report. end insert 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.

(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 begin insert or directories end insert 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 begin delete monthly quarterly end delete begin insert required end insert
update, or begin delete the monthly quarterly update immediately following
that update. end delete begin insert sooner if required by federal law or regulations. end insert

begin delete

(r) Notwithstanding Section 10123.13,

end delete

begin insert (p) end insert begin insert   end insert begin insert (1) end insert begin insert   end insert begin insert Commencing July 1, 2017, notwithstanding Sections
10123.13 and 10123.147, end insert an insurer may delay payment or
reimbursement begin insert owed end insert to a provider begin delete who has not responded end delete begin insert or
provider group for any claims payment made to a provider or
provider group for up to one calendar month beginning on the
first day of the following month, if the provider or provider group
fails to respond end insert to the insurer’s attempts to verify the provider’s
begin delete 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 end delete begin insert information as
required under subdivision (l). The insurer shall not delay payment
unless it has attempted to verify the provider’s or provider group’s
information by all means of communication available to the
insurer, including in writing, electronically, or by telephone. An
insurer may seek to delay payment or reimbursement owed to a
provider or provider group only after the 10-business day notice
period described in paragraph (4) of subdivision (l) has lapsed. end insert

begin insert

(2) An insurer shall notify the provider or provider group 10
days before it seeks to delay payment or reimbursement to a
provider or provider group pursuant to this subdivision. If the
insurer delays a payment or reimbursement pursuant to this
subdivision, the insurer shall reimburse the full amount of any
payment or reimbursement subject to delay to the provider or
provider group no later than three business days following the
date on which the insurer receives the information required to be
submitted by the provider or provider group pursuant to
subdivision (l).

end insert

begin insert (3) end insert begin insert   end insert begin insert An end insert 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 begin insert or
directories end insert pursuant to this section.

begin delete

(s) (1) In

end delete

begin insert (q) end insert begin insert   end insert begin insert In end insert circumstances where the department finds that an insured
reasonably relied upon begin insert materially end insert inaccurate, incomplete,
begin delete confusing, end delete 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 begin delete insurance
contract. end delete begin insert health insurance policy. end insert Prior to requiring reimbursement
in these circumstances, the department begin delete must end delete begin insert shall end insert conclude that
the services received by the insured were covered services under
the insured’s begin delete insurance contract. end delete begin insert health insurance policy. end insert 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.

begin delete

(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 delete begin delete

(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 delete begin insert

(r) Whenever an insurer determines as a result of this section
that there has been a 10-percent change in the network for a
product in a region, the insurer shall file a statement with the
commissioner.

end insert begin delete

(t)

end delete

begin insert (s) end insert  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.

begin delete

(u)

end delete

begin insert (t) end insert  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.

begin insert

(u) For purposes of this section, “provider group” means a
medical group, independent practice association, or other similar
group of providers.

end insert

SEC. 4.  

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.