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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