BILL ANALYSIS                                                                                                                                                                                                    Ó






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          |SENATE RULES COMMITTEE            |                        SB 137|
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                                   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.










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          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.








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             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  







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               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








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          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  







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                 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  







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            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. 







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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.
          
          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 







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          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  







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          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."








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          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


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