BILL ANALYSIS Ó
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: SB 137
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|AUTHOR: |Hernandez |
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|VERSION: |March 26, 2015 |
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|HEARING DATE: |April 15, 2015 | | |
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|CONSULTANT: |Teri Boughton |
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SUBJECT : Health care coverage: provider directories
SUMMARY : Requires a health plan or insurer to make available a provider
directory or directories that provide information on contracting
providers, including those that accept new patients. Prohibits
a provider directory from including information on a provider
that does not have a current contract with the plan or insurer.
Requires the plan or insurer to update the provider directory or
directories at least weekly, with any change to contracting
providers and ensure that the provider directory meets or
exceeds a 97 percent accuracy rate.
Existing law:
1.Requires a health plan to provide, upon request, a list of the
following contracting providers, within the enrollee's or
prospective enrollee's general geographic area:
a. Primary care providers;
b. Medical groups;
c. Independent practice associations;
d. Hospitals; and,
e. 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.
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2.Requires this list to indicate which providers have notified
the plan that they have closed practices or are otherwise not
accepting new patients at that time, and that the list is
subject to change without notice.
3.Requires the list to include a telephone number that enrollees
can contact to obtain information regarding a particular
provider and information on whether or not that provider has
indicated that he or she is accepting new patients.
4.Requires the plan to provide this information in written form
to its enrollees or prospective enrollees upon request.
Permits a plan, with the permission of the enrollee, to direct
the enrollee or prospective enrollee to the plan's provider
listings on its Internet Web site.
5.Requires plans to ensure that the information provided is
updated at least quarterly. Permits a plan to satisfy this
update requirement by providing an insert or addendum to any
existing provider listing.
6.Requires insurers to provide group policyholders with a
current roster of institutional and professional providers
under contract to provide services at alternative rates under
their group policy and make such lists available for public
inspection during regular business hours at the insurer's or
plan's principal office within the state.
This bill:
1.Requires a health plan or insurer to make available a provider
directory or directories that provide information on
contracting providers, including those that accept new
patients, as specified. Prohibits a provider directory from
including information on a provider that does not have a
current contract with the plan or insurer.
2.Requires a plan or insurer to 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 regulators, and
other state or federal agencies can easily identify which
providers participate in which networks for which products.
SB 137 (Hernandez) Page 3 of ?
3.Requires a health plan or insurer to use the same consistent
classification method in provider contracts and communications
to ensure that providers can identify the products and
networks that they are legally contracted to provide services
in. Requires the classification to be consistent across plans
in order to permit the regulators and other state or federal
agencies to construct multi-plan directories.
4.Requires the provider directory or directories to be available
on the plan's or insurer's Internet Web site and available
without any requirement that a member of the public or
potential enrollee indicate intent to obtain coverage from the
plan or insurer, without demonstrating coverage with the plan
or insurer, providing a policy number, providing any other
identifying information, or creating or accessing an account,
and accessible through a clearly identifiable link or tab.
5.Requires searches by name, practice address, National Provider
Identification number, California license, facility or
identification number, product, tier, provider language,
medical group or independent practice association, hospital or
clinic, as appropriate.
6.Requires the Department of Managed Health Care (DMHC) to
direct the plan and the California Department of Insurance
(CDI) to direct the insurer to make the information available
on another technology if one emerges that takes the place of
the Internet in a timeframe that allows for implementation not
to exceed six months.
7.Requires the plan or insurer to make a paper copy of the
directory or directories available upon request.
8.Requires the plan or insurer to update the provider directory
or directories, at least weekly, with any change to
contracting providers, including all of the following:
a. Instances where a contracting provider is no
longer accepting new patients, or that the provider
moved or relocated from the contracted service area of
the plan or insurer or has retired or has otherwise
ceased to practice;
b. Instances where the contracting provider
group, if any, has identified that the provider is no
longer associated with the group or is no longer
SB 137 (Hernandez) Page 4 of ?
accepting new patients;
c. Instances where the plan or insurer identified
a change based on an enrollee complaint that a
provider was not accepting new patients or was
otherwise not available; and,
d. Any other relevant information that has come
to the attention of the plan or insurer affecting the
content of the provider directory.
9.Requires the provider directory or directories to 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.
10.Requires a full service health plan and insurer to include
all of the following in the directory or directories:
a. Provider's name, location(s), and contact
information;
b. Type of practitioner;
c. National Provider Identification number;
d. California license number and type of license;
e. The area of specialty, including board
certification, if any;
f. For physicians, the medical group, if any;
g. Nurse practitioners, physician assistants,
psychologists, acupuncturists, optometrists,
podiatrists, chiropractors, licensed clinical social
workers, marriage and family therapists, professional
clinical counselors, and nurse midwives, to the extent
their services may be accessed and are covered through
the contract with the plan or insurer;
h. For federally qualified health centers (FQHCs)
or primary care clinics, the name of the FQHC or
clinic;
i. The name of the provider and the name of the
FQHC or clinic for any provider described in f or g
above who is employed by a FQHC or primary care
clinic;
j. Hospital admitting privileges, if any, for
physicians and other health professionals contracted
with the plan or insurer whose scope of services for
the plan include admitting patients and who have
admitting privileges at a hospital;
aa. Non-English language, if any, spoken by a
health professional as well as non-English language,
SB 137 (Hernandez) Page 5 of ?
if any, spoken by staff to the provider;
bb. Whether a provider is accepting new patients
with the product selected by the enrollee or potential
enrollee;
cc. Network tier to which the provider is
assigned, if applicable. Defines "Tiered provider
network" as a network of participating providers that
has been divided into subgroupings differentiated by
the health plan or insurer according to enrollee cost
sharing levels or quality scores.
dd. A disclosure that enrollees are entitled to
full and equal access to covered services, including
enrollees with disabilities as required under relevant
federal law; and,
ee. All other information necessary to conduct a
search pursuant to 5 above.
11.Establishes similar requirements as in 10) above for
specialized health plans.
12.Requires by March 15, 2016, DMHC and CDI to develop provider
directory standards that are sufficient to permit a single
uniform electronic directory that would allow a member of the
public to determine whether a physician or other provider is
available to an enrollee of the California Health Benefit
Exchange (Covered California), a beneficiary of the Medi-Cal
program enrolled in a Medi-Cal managed care plan, or an
enrollee or potential enrollee of group coverage. Requires by
September 15, 2016, or no later than six months after the date
that provider directory standards are developed by DMHC and
CDI, a plan or insurer to use the standards for each product
offered by the plan or insurer.
13.Requires a directory or directories to be provided to DMHC or
CDI in a format required by DMHC or CDI.
14.Requires the plan or insurer to demonstrate no less than
quarterly that the information is consistent with information
required under existing law related to timely access to care
and for DMHC plans adequate provider networks.
15.Requires the plan or insurer to ensure that the accuracy of
the provider directory meets or exceeds 97 percent.
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16.Requires the plan or insurer to contact any provider listed
in the directory which has not submitted a claim or encounter
data, if claims are not submitted, in the past three months
for primary care providers, or six months for specialty care
providers, to determine whether the provider is accepting
patients or referrals from the plan or insurer. Requires a
provider who does not respond within 30 days to be removed
from the provider directory.
17.Requires the plan or insurer to make available an electronic
copy of the directory, or upon request, one physical copy, to
the Department of Health Care Services (DHCS) for Medi-Cal
managed care plans, to Covered California for the networks of
the products offered through the exchange, as required by
contract, on request to the Public Employees' Retirement
System, the regulators, and on request by a group purchaser.
18.Requires a plan or insurer to undertake immediate corrective
action to ensure the accuracy of the directory or directories
if informed of a possible inaccuracy.
19.Requires plans or insurers to ensure processes are in place
to allow providers to promptly verify or submit changes to
demographic information and participation status that at a
minimum, include an online interface for providers to submit
verification or changes electronically and to allow providers
to receive an acknowledgement of receipt from the plan or
insurer.
20.Requires providers to verify or submit changes to demographic
information and participation status using this process
according to the terms of their contract with the contracted
health plan or insurer.
21.Requires plans or insurers to allow enrollees to request the
information required by this bill through their toll-free
telephone number, electronically, or in writing. Permits
information provided in written form to be limited by the
geographic region in which the enrollee or potential enrollee
resides or intends to reside.
FISCAL
EFFECT : This bill has not been analyzed by a fiscal committee.
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COMMENTS :
1.Author's statement. According to the author, Californians
shopping for health insurance must have confidence in provider
directory information in order to make coverage decisions,
especially when health insurance coverage is required by
government for most of the population. For too long,
Californians have been unable to rely on information provided
by health insurance carriers and health care providers about
which carriers their existing health care providers are
contracted with, and if a provider is taking new patients.
California's provider directory law also needs to be updated
to reflect technological advancements away from paper-based
directories. Federal and state health insurance regulations
have established requirements on different segments of health
insurance carriers, but uniform standards are necessary to
ensure consistency among carriers, markets and programs. This
bill would establish uniform provider directory standards and
require weekly updates of online directories.
2.Federal Regulations. The following regulations have been
issued by the federal government relative to health plans and
insurers participating in exchanges under the Patient
Protection and Affordable Care Act (ACA). These plans and
insurers are referred to as qualified health plans (QHPs).
Each QHP that uses a provider network must ensure that the
network of contracted providers meets the following standards:
a. The QHP provider directory must be available to an
exchange for publication online in accordance with
guidance from the federal Department of Health and Human
Services (HHS) and to potential enrollees in hard copy
upon request;
b. A QHP must identify providers that are not accepting
new patients; and,
c. For plan years beginning on or after January 1,
2016, a QHP must publish an up-to-date, accurate, and
complete provider directory, including information on
which providers are accepting new patients, the
provider's location, contact information, specialty,
medical group, and any institutional affiliations, in a
manner that is easily accessible to plan enrollees,
prospective enrollees, the state, the exchange, HHS and
United States Office of Personnel Management. A provider
directory is easily accessible when:
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i. The general public is able to view all of
the current providers for a plan in the provider
directory on the QHP's public Web site through a
clearly identifiable link or tab and without
creating or accessing an account or entering a
policy number; and
ii. If a carrier maintains multiple provider
networks, the general public is able to easily
discern which providers participate in which plans
and which provider networks.
3.CDI Regulations. Recently approved emergency regulations
issued by CDI require network provider directories to be
offered to accommodate individuals with limited English
proficiency or disabilities, and require an insurer to post
its current network provider directory on its internet web
site, updated weekly, and available online to both covered
persons and consumers shopping for coverage without
requirements to log on or enter a password or a policy number.
The CDI regulations require an insurer to maintain accurate
provider directories for its networks and demonstrate the
accuracy of its directories to CDI. Insurers must inform its
covered persons of the availability of a paper copy of the
network provider directory at no cost in its coverage material
and on its internet web site, and requires the paper copy of
the network provider directory to be printed annually and
updated quarterly during the calendar year. The regulations
require, if an insurer has more than one provider network,
that it be reasonably clear to a covered person which network
applies to each insurance product. Covered persons must be
informed of the availability of translations and interpreter
services in languages other than English. The regulations
require the following listing for each provider: the name of
the provider, the specialty area or areas of the provider,
whether the provider is currently accepting new patients,
whether the provider may be accessed without referral, the
location(s), including address, and contact information for
the provider, the gender of the provider, languages spoken by
the provider, languages spoken by office staff, list of
network facilities where the provider has admitting
privileges, whether the provider is a primary care physician
(PCP), and whether the office is accessible under the
Americans with Disabilities Act (ADA). The network provider
directories, both printed and online, are required to also
inform consumers of the insurer's obligation to offer
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consumers primary care and specialty care within the specified
time frames. The network provider directories, both printed
and online, must identify those contracting providers who are
themselves multilingual or who employ other multilingual
providers and/or office staff, based on language capability
disclosure forms signed by the multilingual providers and/or
office staff, attesting to their fluency in languages other
than English. The regulations require an insurer to promptly
notify those patients seen by a provider within the past year
when the provider, for any reason, leaves the insurer's
network. This may include, but is not limited to, the
provider's decision to retire or stop practicing medicine for
other reasons, relocating to an area outside the service area,
leaving a group practice that is included as a participant in
the network, or withdrawing from a network for any other
reason.
4.Medi-Cal Requirements. Plans contracting for Medi-Cal managed
care enrollees must meet state and federal provider directory
requirements. The following are provisions from contracts
between DHCS and Medi-Cal managed care plans. "Contractor
shall cooperate with the DHCS Enrollment program and shall
provide to DHCS' enrollment contractor a list of network
providers (provider directory), linguistic capabilities of the
providers and other information deemed necessary by DHCS to
assist Medi-Cal beneficiaries, and Potential Enrollees, in
making an informed choice in health plans. The provider
directory will be submitted every six months and in accordance
with MMCD Policy Letter 00-02." Additionally, Medi-Cal
managed care plans are required to comply with provider
listing requirements applicable to DMHC regulation health
plans and they are required to report quarterly and at the
time of a significant change to the network affecting provider
capacity and services, including: 1) Change in services or
benefits; 2) Geographic service area or payments; or 3)
Enrollment of a new population. The report is required to
identify the number of primary care providers, provider
deletions and additions, and the resulting impact to: 1)
geographic access for the members; 2) cultural and linguistic
services including provider and provider staff language
capability; 3) the percentage of traditional and safety-net
providers; 4) the number of members assigned to each primary
care physician; 5) the percentage of members assigned to
traditional and safety-net providers; and 6) the network
providers who are not accepting new patients.
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5.Audit Request. In the summer of 2014, the Joint Legislative
Audit Committee approved a request by Senator Ricardo Lara to
examine California's Medi-Cal managed care provider
directories, provider networks and the current regulatory
framework to ensure the accuracy of the provider directories.
According to the request, there were several alarming reports
about the difficulty some Medi-Cal beneficiaries are having in
finding Medi-Cal providers who will accept new patients. The
audit conducted by the Bureau of State Audits is expected
sometime this summer.
6.Related Legislation. AB 533 (Bonta) requires a health plan
contract or health insurance policy issued, amended, or
renewed on or after January 1, 2016, to provide that if an
enrollee or insured obtains care from a participating
facility, as defined, at which, or as a result of which, the
enrollee or insured receives covered services provided by a
nonparticipating provider, as defined, the enrollee or insured
is required to pay the nonparticipating provider only the same
cost sharing required if the services were provided by a
participating provider. AB 533 is scheduled for a hearing in
the Assembly Health Committee on April 21, 2015.
7.Prior legislation.
a. SB 964 (Hernandez), Chapter 573, Statutes of 2014,
increases the oversight of health plans and compliance
with timely access to care requirements by requiring
health plans to annually report specified network
adequacy data, authorizing health plans to include
provisions requiring compliance with timely access in its
provider contracts, and requiring DHCS to publicly report
its findings of finalized medical audits as soon as
possible, as specified, and to share those findings and
other information with respect to health plans regulated
by DMHC.
b. AB 2179 (Cohn), Chapter 797, Statutes of 2002,
requires DMHC and CDI to develop and adopted
regulations to ensure that enrollees have access to
needed health care services.
8.Support. The California Pan Ethnic Health Network (CPEHN),
cosponsor of this bill writes, health care coverage alone does
not ensure consumers can access care. Consumers rely on
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information supplied by health plan provider directories to
make decisions about which plans best meet their needs. Errors
and misleading information in provider directories can become
a huge obstacle for individuals in accessing care. These
obstacles are exacerbated in communities of color who often
face an insufficient distribution of providers, transportation
barriers, language barriers, and lack of flexible hours.
Incorrect or out-of-date provider directories further limit
the number of available providers, may delay timely access to
care, require excessive amount of travel or prevent a consumer
from receiving culturally and linguistically appropriate care.
Consumers Union and Health Access California, also cosponsors
of this bill, writes without knowing which providers are in
the network, consumers cannot keep medical costs under control
and avoid the surprise medical bills that can come with
getting care from out-of-network providers. California
recognized the importance of provider directories by enacting
a law on access to them a decade ago. Since that time,
technology has transformed, making information once available
only in telephone book-sized tomes now more readily accessible
online. The statutes have not been updated to reflect both
advances in technology and the transformation of the health
insurance landscape of active consumers shopping for coverage.
The first ACA open enrollment period drew significant
attention to the issue of inaccurate and insufficiently
accessible provider directories. Some consumers faced
difficulty getting accurate provider information prior to
enrolling; others once enrolled found that the directories
they relied upon were not up to date. These issues prompted
DMHC to audit two of California's largest insurers last summer
and fall, revealing deficiencies in their provider
directories. Health Access California believes this bill is
the next logical step now that timely access and network
adequacy requirements are in place. The Montebello Unified
School District supports this bill indicating that many of
their employees selected a certain CalPERS plan based on
misinformation by the plan that a community hospital was in
the network. This hospital continues to be listed in the
network three months later despite CalPERS responding to the
district that it was working with the plan "to ensure their
website is clear and understandable to our members."
9.Concerns. The California Association of Health Plans (CAHP)
writes that the accuracy of the directory should be based on a
shared responsibility between plans and practitioners. CAHP
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has concerns regarding the volume of detail that is to be
incorporated into an on-line database with a 97 percent
accuracy rate. The concern is based on the heavy reliance of
practitioners and medical groups to maintain accurate records,
such as phone numbers, which will require a higher degree of
shared responsibility between practitioners and plans. CAHP
states that it would be helpful to collectively consider a
mechanism for health plans to utilize, outside of contractual
requirements, to ensure that practitioner information
contained in the database is accurate. CAHP's other concerns
with the bill surround the timeframes and efforts spent in
regard to the frequency of the updates and CAHP recommends
that only data which will assist enrollees in identifying
network practitioners be included in the directory. Some
health plans, including smaller regional or Medi-Cal managed
care plans, may have issues with implementing the new
requirements in the timeframes contained in the bill. Plans
will be required to make a significant investment in
information technology and possibly new network management
staff. There are significant technical issues to be
considered for implementation, such as in identifying data
processing issues to incorporate on-line practitioner feedback
into the on-line directory. CAHP also points out that
practitioners have one year to bill for care provided, however
the bill requires that a practitioner be contacted if a
primary care provider has not submitted a claim or encounter
data for three months and specialty providers for six months.
10.Amendments. The author intends to request the committee adopt
several technical and clarifying amendments.
SUPPORT AND OPPOSITION :
Support: California Pan-Ethnic Health Network (co-sponsor)
Consumers Union (co-sponsor)
Health Access California (co-sponsor)
American Cancer Society Cancer Action Network
American Federation of State, County, and Municipal
Employees, AFL-CIO
Asian Law Alliance
California Academy of Family Physicians
California Black Health Network
California Chapter American College of Emergency
Physicians
California Chapter National Association of Social
Workers
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California Council of Community Mental Health Agencies
California Coverage and Health Initiatives
California Labor Federation
California Primary Care Association
California Optometric Association
CALPIRG
California School Employees Association, AFL-CIO
Children Now
Children's Defense Fund California
Montebello Unified School District
National Health Law Program
National Multiple Sclerosis Society California Action
Network
The Children's Partnership
Southeast Asia Resource Action Center
Susan G. Komen, Central Valley Affiliate
Susan G. Komen, Inland Empire Affiliate
Susan G. Komen, Los Angeles County Affiliate
Susan G. Komen, Orange County Affiliate
Susan G. Komen, Sacramento Valley Affiliate
Susan G. Komen, San Diego Affiliate
Susan G. Komen, San Francisco Bay Area Affiliate
United Way of California
Western Center on Law and Poverty
Oppose: None on file
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