BILL ANALYSIS Ó ----------------------------------------------------------------- |SENATE RULES COMMITTEE | SB 137| |Office of Senate Floor Analyses | | |(916) 651-1520 Fax: (916) | | |327-4478 | | ----------------------------------------------------------------- THIRD READING Bill No: SB 137 Author: Hernandez (D) Amended: 6/1/15 Vote: 21 SENATE HEALTH COMMITTEE: 8-0, 4/15/15 AYES: Hernandez, Hall, Mitchell, Monning, Nielsen, Pan, Roth, Wolk NO VOTE RECORDED: Nguyen SENATE APPROPRIATIONS COMMITTEE: 6-0, 5/28/15 AYES: Lara, Beall, Hill, Leyva, Mendoza, Nielsen NO VOTE RECORDED: Bates SUBJECT: Health care coverage: provider directories SOURCE: California Pan-Ethnic Health Network Consumers Union Health Access California DIGEST: This bill 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. SB 137 Page 2 ANALYSIS: Existing law: 1)Requires a health plan to provide, upon request, a list of specified contracting providers, within the enrollee's or prospective enrollee's general geographic area, 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. 2)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. 3)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. 4)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. 5)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. SB 137 Page 3 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. 3) 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. 4) Requires searches by name, practice address, National Provider Identifier number, California license, facility or identification number, product, tier, provider language, medical group or independent practice association, hospital or clinic, as appropriate. 5) 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. 6) Requires the plan or insurer to update the provider directory or directories, at least weekly, with any change to contracting providers as specified. 7) 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. 8) Establishes requirements on full service and specialized health plans and insurers for inclusion in the directory or SB 137 Page 4 directories. 9) Requires by March 15, 2016, DMHC and CDI to develop uniform provider directory standards which would allow directories to be aggregated and searchable to determine the plan a physician or other provider is available through. 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. 10) 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. 11) Requires the plan or insurer to ensure that the accuracy of the provider directory meets or exceeds 97 percent. 12) 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. 13) 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. 14) 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. Comments SB 137 Page 5 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. Regulations have been issued by the federal government relative to health plans and insurers participating in exchanges under the 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: i) The general public is able to view all of the current providers for a plan in the provider directory on SB 137 Page 6 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 consumers primary care and specialty care within the specified time frames. The network provider directories, both printed SB 137 Page 7 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 the Department of Health Care Services (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 the Medi-Cal Managed Care Division 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. SB 137 Page 8 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. FISCAL EFFECT: Appropriation: No Fiscal Com.:YesLocal: Yes According to the Senate Appropriations Committee: One-time costs of about $160,000 in 2015-16 and $200,000 in 2016-17 to work with stakeholders, develop standards, and issue regulations by the Department of Insurance (Insurance Fund). One-time costs, likely between $150,000 and $300,000 to work with stakeholders, develop standards, and issue regulations by the Department of Managed Health Care (Managed Care Fund). No significant costs to the Medi-Cal program are anticipated. The Department of Health Care Services indicates that any additional costs to Medi-Cal managed care plans would not likely lead to increased rates paid to those plans by the state. SUPPORT: (Verified5/29/15) California Pan-Ethnic Health Network (co-source) Consumers Union (co-source) Health Access California (co-source) American Cancer Society Cancer Action Network American Federation of State, County, and Municipal Employees, AFL-CIO Asian Law Alliance California Academy of Family Physicians SB 137 Page 9 California Academy of Physician Assistants California Association of Health Underwriters California Black Health Network California Chapter American College of Emergency Physicians California Chapter National Association of Social Workers California Chronic Care Coalition California Council of Community Mental Health Agencies California Coverage and Health Initiatives California Dental Association California Labor Federation California Primary Care Association California Optometric Association California Teachers Association CALPIRG California School Employees Association, AFL-CIO Children Now Children's Defense Fund California Having Our Say Coalition Mental Health America of California Montebello Unified School District National Association of Social Workers - California Chapter 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 OPPOSITION: (Verified5/29/15) Delta Dental ARGUMENTS IN SUPPORT: The California Pan Ethnic Health SB 137 Page 10 Network (CPEHN), cosponsor of this bill writes, health care coverage alone does not ensure consumers can access care. Consumers rely on 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." SB 137 Page 11 ARGUMENTS IN OPPOSITION: Delta Dental writes that SB 137 would set unrealistic standards and requirements for provider directories. Delta Dental supports the goal of improving accuracy of provider directories and agrees with measures to help ensure providers update their online information but this bill contains provisions that are unworkable and in consistent with the author's goal. Delta Dental has suggested amendments that providers have an obligation to avail themselves of easily accessed systems Delta Dental makes available to update their directory listing, that notifications from providers regarding changes to their information should trigger a 30-day maximum limit on the plan's obligation to update the online directory, and the frequency of a provider's claims submission over any period of time is inappropriate, inefficient and ineffective means for determining when or if a provider should be removed from a provider directory. Prepared by:Teri Boughton / HEALTH / 6/1/15 16:58:16 **** END ****